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i UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: 1T0 A Q p , - I Inspection Date: Facility Address: 3 3 G4j,17'b- City- Name of Designated UST Operator Conducting Inspection: S International Code Council Certification No.: SD- kA 3-).,S _ Expiration Date Signature: L A, --tPhone: �� i b _j / ext. NIA=Not Applicable Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. Is the monitoring stem powered on and in proper qpgaung mode? ❑ ❑ 2. Is the monitoring not currently any leak alarms? ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the Designated UST Attach a copy ofthe alarm histo rMorift to this inspection form. 4. Has each alarm for the month been ded to atel . UST SYSTEM INSPECTION 5. Are tank-top containment sumps fire of water,debris,and hazardous substance? Note:Yrhe answer to Item a was"Yes, skip to Item b.Sumps where an alarm has occurred in the past month must be hapected f a qualified service technician has not responded to,and properly addressed the cause ofthe alarm.Dbcumentabon Yen jmgservice should be attached to this report Yes No Yes No Sump Location: 12d S Location: S Location: S Location: 6. Are spill buckets c ontaimnent structures) of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank I ID— Tank 4 M— Tank 2 ID— ❑ Tank 5 ID— 01 ❑ ❑ Tank 3 ID— ❑ I L1 I Tank 6 ID— I ❑ 7. Are wider-dispenser containment areas free of water,debris,and hazardous substance? YesI No I N/A Yes I No N/A Dispenser—1/2 12 10 1 U Dispenser-9/10 Q I ❑ Dispenser—3/4 01 L3 ❑ Dispenser—11/12 Dispenser—5/6 El I-❑ ❑ Dispenser—13/14 ❑ ❑ ❑ Dispenser—7/8 = ❑ Di enser-15/16 [] ❑ ❑ 8. Leak detection is properly located within under-dispenser containment. YesI No N/A Yes No I N/A Dispenser—1/2 1103 Di —9/10 ❑ ❑ Di —3/4 Di ser-11/12 ❑ ❑ ❑ Di —5/6 ❑ Dispenser—13/14 El Dispenser—7/8 Di —15/16 ❑ u I Q- 1 Ell, PAPERWORK INSPECTION Yes No NIA Date Done 9. Monitoring System Certification was pompleted within the past 12 months? El El 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ❑ 11. SO]bucket containment structure testing completed within the past 12 months? 12. -Line ti tresstesting completed within the required time frame? ❑ 13. Seconddary containment tests completed within the fired time frame? 14. Enhanced Leak Detection completed within the required time frame? R- 15. Other required testinghnaintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance: Describe Test/Maintenance: I El I El FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facilityem to received the on-the-job trainin within the past ear? ❑ 17. 1 Have all facili to ees hired within the 30 days received the Mguired on-the-'ob trrinin 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-W www.anide org MUM