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0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Inspection Date: 16 <br /> Facility Address: 3b'�2 �)qQ y ifZ City <br /> Name of Designated UST Operator Conducting Inspection: C.w y At <br /> International <br /> J A 4i <br /> International Code Council Certification No.: Z 4 3-� j_ Vl C Expiration Date: N <br /> Signature: Phone: <br /> �i)u V 6'�7jl�2 ext. <br /> N/A=Not Applicable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No I N/A <br /> I. Is the monitoring stem powered on and in proper operating mode? 131 f-1 I El <br /> 2. Is the monitoring system not currently showing any leak alarms? 2 ❑ I ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the V ❑ ❑ <br /> Designated USTOperator? Attach a copy of the alarm history report/logreport/log to this ins ection orm. <br /> 4. 1 Has each alarm for the previous month been re nded-77777 <br /> to a riatel ? <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:Ifthe answer to Item 4 was "Yes, slap <br /> to Jtem 6. Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to,and <br /> properly addressed,the cause of the alarm.Documentation verif_ying ro nate service should be attached to this report <br /> Yes No Yes No <br /> Sump Location: 0 ❑ _ Sum Location: ❑ <br /> S Location: Sum Location: ❑ <br /> 6. Are spilI buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/AYes No N/A <br /> Tank 1 ID— ❑ Tank 4 ID— EEII El El <br /> Tank 2 ID— [ITank 5 ID— ❑ ❑ <br /> Tank 3 ID— ]NJ ElL1Tank 6 ID— ❑ ❑ <br /> 7. Are under-dispenser containment areas fr of water,debris,and hazardous substance? <br /> Yes No NIAII No I N/A <br /> Dispenser— 1/2 In ❑ Dispenser—9/10 1 El ❑ <br /> Dispenser—3/4 ❑ LJ Dispenser—11/12 ❑ t <br /> Dispenser-5/6 ❑ Dis ser—13/14 <br /> Dispenser-7/8 E]9 ❑ Dis enser—15/16 ❑ <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> Yes No NIAI Yes I No I N/A <br /> Dispenser—1/2 MIQ Q I Dispenser—9/10 El I ❑ I ❑ <br /> Dis enser—3/4 ❑ ❑ I Dispenser—11/12 El I El I ❑ <br /> Di ser—5/6 ❑ ❑ I Dispenser—13/14 EJ I LJ I ❑ <br /> Di ser—7/8 El ❑ I Dis ser—15/16 ❑ I ❑ I ❑ <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? ❑ <br /> LCS <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? 0 ❑ ❑ <br /> 11. Spill bucket containment structure testing completed within the past 12 months? ❑ ❑ <br /> 12. Line tightness testing completed within the required time frame? <br /> M <br /> ❑ <br /> 13. Secondary containment tests completed within the required time frame? ra <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ <br /> 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. <br /> Describe Test/Maintenance: ❑ IJ ❑ <br /> Describe Test/Maintenance: ❑ ❑ I ❑ <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facility employees received the required on-the-job training within the past ear? ❑ ❑ <br /> 17. Have all facili em to ees hired within the past 30 days received the re uired on-the-'ob training.? ❑ <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidoes.org 9/26/05 <br />