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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION I tty~1Vauie: C Inspection Late: Eacilttv .4dclress: Cil_v: Mame of Designated UST Operator Conducting ins}xctlont: Evangelina Barmso-Traylor International C e Council CertificationNo.: 8200889 -UC Expiration Date: 3/10%2017 Signature: i t Phone: (909) 455-2275 ext. n,a =NM a...il:nt,i. Item NION.IT01UNG PANEL / ALARM HISTORY Yes No N/A 1,Is the monitorings stem powered on and in proper operating mode? the alarm. Documentation Peri ins^, appropriate servlce shoidd be attached to r6tde re:gW1. 01 Elz Yes Is the monitoring system not currently showing any leak alarms`' o 3. Ts the Alartn History Report/log for the previous month available, and has it been reviewed by the Designated UST C? orator? (ritlach a co iv of the alarm history repo-11oo to t61is inspection Form. ) l Sump Location. 4 Hay each txl€trnt for the revtous month been rc c tdpd to a rc rtrltc} ?or m _ Arc spill buckets (cotttainnaent strut tri s) free of'water, debris. and hazardous substance? Yes No N/A Yes I ts.7liN�.71�tNu � �►1►7rut�I � t��►i �. Are tank -top containment sumps free of water, debris. and hazardous substance? Not, 1J*the amsrcer to Item 4 was "fes, "skij, to Item 6. Samps where on alarm flay occurred in the paw 11millf tmvt be inspected if a paliJied service ledstr(rion Iran nol responde,l to..nnr' prope,ly addresseet, iTDe cause o the alarm. Documentation Peri ins^, appropriate servlce shoidd be attached to r6tde re:gW1. Yes �I'es o Sump Location: — r ,� Sump Localiun:��'Li c Sum Loation: l Sump Location. 6. m _ Arc spill buckets (cotttainnaent strut tri s) free of'water, debris. and hazardous substance? Yes No N/A Yes No N/A Tank 11 - Tank 41D - Tank 2 ID - ___...._. i . Tani: 5 ID - Tank .i ID- ® , Tank 6 iD- El 0 %. Are under -dispenser enser-ontklinment areas free of water, debris, and hazardous substance? Yes I No N/A Yes No N/A Flispenscr -lit i Dispenser - 9/10 ®is inset 3/4 ® Disp ser 11/12 ❑ Dispenser 'iib j0 L)isnsvr 13114 ❑ I7ls riser 7/8 � Usspehaer- 15/16 � � 8. Teak detectierl oy lototed within tinder-dis aunsee containment. _ - Yes No N/A Yes o N/A e L�irsi 112 ❑ _. ® lata onset 9/70 ❑.. —�.... -- -- Dispenses 3t l ❑ Dispenser- l I,'i' ❑ � Dispenser 5,`6 _- � ❑ 1lt�tensser, 1 /14 — �t ___.. Dispenser 718 � ❑ Dispenser-- 15,16 PA PERWORh INSPECTION Yes No N/A Diate L1oiIe u cin t ertilic anon wa, completed within the oast 1? months? ❑ i El� ' x 10 L�j'c [.oak Detectors were tested:"Certified within the pest 12 months'1 fff❑-' ❑ V _ — I ll, Spill bucket (containment stiuctine) testrrag conrpleted within the past 1' nionths? 12. 1_11,11e n ae Qhtne,s tc, tin_gl completed w=ithin the required tm -nne Irae? 01 ❑ �i 1 i i ccontH re Connatailent tctitS i atttl Ettrd iiithan the required time I it re> ` 1 ,• ❑ ❑ ' � r 14, 11111ced Leak Detection concluitcd time ha 1plcted within the renre" ❑�%j.. ❑ f t 15. Other required testinginliinteuance was completed +vilhm recltitiLei tune frame'' (IJst testonrcunteiranc items Mum) Describe Test"Nil intenance: _ _ F1 ❑ __ _-. Describe Test M ainten ince ® � ❑ ! 1CII ITI 1,ly1Pi OYEE TRAINING Yes i No N/A lb within the pati,}ear' ❑ l /. I i lave all fleiht3, employees hued watlun thepast 30 days received the E!1quired on the job training.) ❑ i ❑ _ \�ote: plam auy "Nv" answers in the "Coittments"section on the fullowing page. "hhose issues require correct.iye action from the UST owiicr/operator. UN -057- 1/2 W%%iv.uiidocs.org W26/05