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0 • <br /> } UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: IU-i d 'f' Inspection Date: 6 _\ _ . )_.�, r*,–)— <br /> Facility Address: W A-V City: C r V L, <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: tJ a 113 Expiration Date: <br /> Signature: Wil, ,C titin Phone: ovq)qw_9/-(?ext. <br /> N/A=Not Appftabie <br /> Item MONITORING PANEL/ALARM HISTORY Yes No N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? <br /> 2. Is the monitoring stem not currently showing any leak alarms? ❑ ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ <br /> Designated USTOperator? Attach a copy of the alarm history reportflog to this ins ection arm. <br /> 4. Has each alarm for theprevious monthbeen R1 ❑ ❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note.f the answer to Item 4 was"Yes,^skip <br /> 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 <br /> properly addressed,the cause ofthe alarm.Documentation vert ro riate service should be attached to this report <br /> Yes No Yes No <br /> Sump Location: ❑ Sum Location: <br /> _,_,jS Location: S Location: <br /> 6. Are spill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID– ❑ 1 ❑ Tank 4 ID– ❑ ❑ <br /> Tank 2 ID– 9TEIT❑ Tank 5 ID F1 I ❑ I ❑ <br /> Tank 3 ID– jV1101 ❑ I Tank 6 ID– ❑ I ❑ <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes No NiAI es I No N/A <br /> Dispenser– 1/2 ❑ ❑ Dispenser–9/10 ❑ <br /> Dispenser–3/4 ❑ Dispenser–11/12 ❑ I ❑ <br /> Di er-5/6 ® Ej I Dispenser–13/14 ❑ ❑ ❑ <br /> Dispenser–7/8 LJ I El I ❑ Dispenser–15/16 ❑ 10 1 ❑ <br /> 8. Leak detection is properly located within under-dispenser containment. <br /> Yes I No N/A Yes No N/A <br /> Dispenser–1/2 ❑ I ❑ I Dispenser–9/10 ❑ ❑ ❑ <br /> Dispenser–3/4 Di enser–11/12 <br /> Dispenser–5/6 ❑ Di ens er–13/14 ❑ El ❑ <br /> Dispenser–7/8 ❑ ❑ Dis ser–15/16 ❑ ❑ <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? ❑ ❑ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ❑ <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 /> 13. Secondary containment tests completed within the required time frame? <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: jElInj ❑ <br /> Describe Test/Maintenance: I ❑ 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? I &= ❑ <br /> 17. Have all facili to ees hired within the past 30 da s received the re uired on-the-'ob training-9 Jul I ❑ <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.nnidocs.org 9/26/05 <br />