DERR-2024-013026

UST Operator Inspection -Utah
YEAR
Factityname (acl?Cady Maoutan Fadl1D 2 0004 22
Address (OS) JG-AG_Sporor yt BY7HG [Primary ClassBOperator ?4\9/,hash,
NAME(S)AND INITIALS OF PERSON(S)CONDUCTING MONTHLY INSPECTIONS:
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Please respond to ALL of the following questions with a Y (Yes),N (No),or NA (Not Applicable)answer,
PMsattecreYeslALee[als [ona
PCMonthlyInspection-Release Detection
Release detection equipment is operating with no alarms or other unusual[feentageanstonsmretmaemseronermedWYTTyTyly[ulyyA
|2 Records of releasedetection (tanksand piping)arereviewed and current.__1V[YY [VIM |w IW[WIWIWIw [al
Monthly Inspection -Spill Prevention Equipment
2favnmentis undamagedintetandfeefromdeters.ITY YY
LYIY [y ly ly ly ly fyYly|4 |Equipment is free from debris,water,or product.
YY |Ly ral
Ls|Fill Pipe is unobstructed.viviviviY ly ly lyly i yy|
YY IYIY IY tyYYIY[6|Fill cap is un-broken and is securely on the fill pipe.y[y.LY
Doubie walled spill prevention equipment -Interstitial area is free from leaks.Vivi ly vivly iy lyiy &ly|
Initials of person performing Inspection.eee ectol |etl e411 |
Annual Inspection -Containment Sumps Date of annual Inspection
Secondary Containment Sumps Visual Inspection of sump indicates no damage and it is free from debris,water and fuel.
(STP,Dispenser and Transition)The penetration fittings for conduits and piping entering the STP Sumps are intact.
|9 [DoubleWalledSumps___??*Interstitial area is free from leaks.
10 Hand-held release detection Hand-held release detection equipment (bailer,gauge stick,etc.)is serviceable and
equipment operable.
|certify under penalty of law that |am the Class B Operator referenced above and that |am familiar with information on this form
and that it is true,accurate and was completed in accordance with R311-203-7.
Comments/Follow up:
Turn over for record of Interstitial Monitoring visual inspections and Impressed Current rectifier checks.