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11 <br />A <br />UNDERGROUND STORAGE TANK SYSTEM <br />DESIGNATED UST OPERATOR NIONTHLYJNSAC''T"10'iN-'REPORT <br />Facility Name: Inspection Date: <br />4 V 7 <br />Item <br />MONITORING PANEL I ALARM HISTORY <br />Yes,7i <br />o <br />N/A <br />1. <br />1 <br />— <br />--= <br />2. <br />Is thcraonitoring system not currently showing any leak- alarms? <br />3. <br />Is the Alarm I hstory Report/log for the previous month available, and has it been reviewed by the <br />C ­ <br />Designated USTOperator? <br />4. <br />Ilan ea It alarm for the ious month been res onded toe ro net; 1 9 <br />USTSYSTEM INSPECTION <br />5. <br />Are tank -top containment sumps free of water, debris, and hazardous sub staree? ,Vote: 11ftheunsiveriolmoi 4war 'Tes, "skip <br />to ?tent 6• Statips where an olorm has occury-ed in the past month ninsf he impected V a quaWred irrvice iveludetian has not respopided to, and <br />_r _ort <br />Yes <br />es NO' <br />Sump Loca�fion, X Sump Location: <br />Sump Locafion--, Sump Location: <br />6, <br />Are spill buckets containment stnxcrur5_free of water, debris, and hazardous substance? <br />—NoNtA <br />Yes <br />V�C_s No <br />N/A <br />Tama 410 - <br />Tank 2 ID - e3 C/ <br />Tank 5 ID - <br />Tank 3 ID - y ---7-❑Tank <br />6 ID - <br />T <br />Are under -dispenser coitainmet areas free of water, debrisand hazardous s substance? <br />- <br />_ <br />_.-.- <br />Yes i No N/A <br />Ws No NIA, <br />Dispenser - 9/7 0 <br />Rjjs �-nser - �3/4 <br />111/12 <br />Dispenser -5/6 <br />0 1 Lj Dispenser 13/14 <br />- �)nser , <br />Disp <br />El I ❑ <br />8. <br />Leak detection is properly located within under -dispenser containment. <br />Yes No NIA <br />Yes No N/A <br />Dispenser - 1/2 Dis enser-9/10 <br />Dispenser Dispenser - I 1/ 12 <br />Q <br />❑ <br />6 isperiser -- 13/14 <br />I ) i s p (it i s -J-5 ) <br />El U, <br />77777�Yes <br />Dispenser Dispenser 15/16 <br />7777 -77777'= <br />U Li �Ll_ <br />PAPERWORK INSPECTION No IN/A <br />DateDone <br />9. <br />i monituring,5YSIC111 Certification Nvusc(�)Jted within the ms( 12 rnonths,1 <br />10. <br />Line Leak Detectors v,,ere tes-ve(I"certified within the past 12) inonths? <br />U <br />)ill bucket (co ti �l 2 Months? <br />ntainnient strudUre) tes i cornpictedo6thin thejj�s <br />1'LiilctWyitricss <br />testing, completed within rcquncd Time trims? ®� El Z <br />_0_07,7 <br />13. <br />Stcondary contaitiniclit tests completed within the required time fra�_ie—?_37-JU•-17T7 <br />_E1 <br />,I 1. <br />'fufl—anced Leulk�etection viy�mp!cLcd within Clic. ii�:guired tune fiame? ❑ H <br />.❑ . ... ........... ... <br />15. <br />_Oth�err I Ltinjd testingiut rrttutanec was completed within required time frame? tLisit test'moinlefumce itemv below) <br />Describe TesuMlaintenance: <br />Desci ibc Tcsi.!tv1aintcnance-. —0 i 0 ❑i <br />7 <br />FACILITY EMPLOYEE TRAINING <br />Yes i No N/A <br />16.l <br />13 all FacilitgeTl1loyees reccived the required on -the thin the pastycar? <br />17, <br />Hay - hast 30 days received The rSuir�d on-the-job training.? <br />veall l'ileility empl(wees hired within the T -a <br />10;: El El <br />Note: Explain any "No" answers in the *'conuiients" section on the I o I lowing page. I nose issues require corrective action I rorn <br />the UST owner/operator, <br />z <br />