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i 0 UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: � 1 © Inspection Date: Facility Address: C 3 Z City: El Name of Designated UST Operator Conducting Inspection: ��C LL,� International Code Council Certification No.: 'j a kA 3 �-1 _ � Expiration Date: #I,, V, �� 2,$)41 Signature: « \o(UL L A Phone: tkcl�1466--j ext. �"�'� N/A=Not Applkable Item MONITORING PANEL/ALARM HISTORY Yesl No N/A 1. Is the monitoring stem powered on and in proper operating mode? 2. Is the monitoring system not currently showing any leak alarms? 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the 0 ❑ ❑ Designated USTOperator? Attach a copy of the alarm history report/logreport1log to this ins ection orm. 4. Has each alarm for the revious month been res onded to a riatel ? ❑ UST SYSTEM INSPECTION - 5. Are tank-top containment sumps free of water,debris,and hazardous substance? ]vote.If the-answer to Item 4 was"Yes,"skip to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to,and properly addressed,the cause of the alarm.Documentation verfjWng appropriate service should be attached to this report. Yes I No Yes No Sump Location: I EI-1 Sump Location: ❑ SumpDation: SUMP Location: ❑ 6. Are spill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A Yes kJN/A_Tank 1 ID- ❑ ❑ Tank 4 ID- ❑Tank 2 ID- ❑ © Tank 5 ID- 0 Tank 3 ID- ❑ ❑ Tank 6 ID- 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes I No I N/A I es No N/A Dispenser- 1/2 1910 -El Dispenser-9/10 Dispenser-3/4 El 10 ❑ 1 Dispenser-11/12 ❑ ❑ Dispenser-5/6 ❑ Dispenser-13/14 ❑ F1Dispenser-7/8 Dis enser-15/16 ❑ 8. Leak detection is properly located within under-dispenser containment. Yes I No NIA Yes No I N/A Dispenser-1/2 1 El Di s enser-9/10 1 F1 I ❑ Dispenser-3/4 n ❑ Dispenser-11/12 ED ❑ ❑ Dispenser-5/6 ❑ Dispenser-13/14 ❑ ❑ Dispenser-7/8 ❑ Dispenser-15/16 ❑ PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? 62 1 El ❑ 10. Line Leak Detectors were tested/certified within the past 12 months? @ ❑ ❑ 11. Spill bucket containment structure testing completed within the past 12 months? ❑ -0- 12. 12. -Line tightness testing completed within the required time frame? '® ❑ ❑ 13. Secondary containment tests completed within the required time frame? 14. Enhanced Leak Detection completed within therequired time frame? 4F Li 1 11 15. Other required testis maintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance: I ❑ I ❑ ❑ Describe Test/Maintenance: ❑ ❑ ❑ .. 7 . _t . .amu FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job training within the past ear? 17. Have all facili to ees hired within the past 30 days received the re uired on-the job trainintO W101 EJ Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.ouldocs.org 926/05