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Adal <br /> M Nw <br /> fD _. N -I <br /> 7 J <br /> N N Z <br /> C) <br /> N0 UNDERGROUND STORAGE TANK SYS`TE1VI` °_ <br /> M DESIGNATED UST OPERATOR MONTIO.Y INSPECTION REPORT � <br /> Cn Facetity Name: Iteapdcdm Daae: to <br /> vt If v.,z y (?_'I .g.v r6 rl .. <br /> O <br /> 1=aci1' Address: c'` n <br /> 13 1 K• Y1f r' y tiit�. ��' S fr. ra X <br /> o <br /> Name of UST cttng Tripe ctr A 1 c � .b 1�o✓r � <br /> Destg�oatecl Operador C,ondu 'on: _._.. _ <br /> 1ntarnstionetl code Qxweil Certification No.: Expo°Drat _ <br /> C7 <br /> st38'� '7 - cJC. k"-3 - �L y <br /> Signa4tcro. <br /> 0, <br /> i s Phone: t cit Zyj) 3 P [Z L <br /> N!A®Not A ' bee <br /> Itra. MONITORING PANEL./ALARM HISTORY MVAWIAI. Is rhe mon' weed on and in mode? <br /> ikrtT <br /> 2. Is the moni not sho leak alarms? <br /> 3. Is the Alarm History RepoMog fpr the previous mouth available,and,has it been reviewed by thTro <br /> Des' UST attach a c the altarx his? r to this <br /> 4. Has each alarm for the previous mouth been to <br /> UST SYSTEM INSPE ON <br /> 5. Are tank-top coatment sumps free of water,debris,and hazardous substance? Notes ljthe marve to tea *^�'Yex"m <br /> 'NA" to teen 6 Sumps where=almm has ocaared In elm parr month mast be tWn*d tfa 9—Nftrd sr,am acbm mr has eer r-poeded <br /> t mW the amw QfdW savtac shoaW be aaadwd m ddr <br /> lyesl No I Yesl No <br /> S Location: iz v lo.r' Sam L.ocadon: <br /> S Loe�on: /r�.,�`J.n Sum La�ttion <br /> 6. Are Vill buckets containment structures)f-ee of water,debris,and hazardous substance? <br /> Yes No N/AI Yes No X/A <br /> Tank l ID- Tank 31D- <br /> Tante 2 lD- I Ll I Tank 4 ID- <br /> Are urxlercontidnmerit areas fine of water,debris,and haze.-dolls substance? <br /> Yes I No NIA Yes No N/A <br /> D -1/2 D' r-9/10 <br /> -3!4ID is -11/12 <br /> 0 1 D' ser-13/14 <br /> D` -718 Di -15116 1 Li I El <br /> 8. Leak detection is located w dein under-duunder-duWnsa contamment <br /> Yes No N/A Yes No N! <br /> Dispenser--1/2 Di -9/10 <br /> -3/4 1 10 D -11/12 10 , <br /> i -5/6 JOD' -13/14 0 LA <br /> -7/9 In D' -15/16 <br /> PAPERWORK INSPECTION Yes No I NIA I Date Bone <br /> 9. Mon' Cmrtificadion was completed within the past 12 months? 2J n- /6 <br /> S000ndaty contaiunew tests completed within the required time fraena? U 0 1 i <br /> 11. Spill budu*(axam meat structure)hxNng oompleod within the past 12 months? - i <br /> 12. Tack ftefing Widtan the I bane&acne? <br /> _M m <br /> 13. Line ' widsin the required tiute$uteri? _ O o <br /> 15. Otbe:tnaaimo noa was com toted within time frame? ist testlmabacnance items hl . a <br /> Desrribc TeartiMairaeeaance:S727 and ST30 * D <br /> T+ast/Ivlaindenance: c' <br /> EIIH I <br /> __. <br /> FACILITY EMPLOYEE TRAINING Yes No N cin <br /> t6. Mtrtvse atN recaived dw tett nirt wtthtut tttG rn <br /> CD 17. Have all hired witihdw dee gt 30 received the nuirad oa-tho-'ob training.?atty rn <br /> uka co ive 8ctliJCt, <br /> 4i ate'"srxticut on the fallnging nam'Thaw. <br /> A dee CISF WN <br /> Tawfcrpaf <br /> „ , <br />