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Site ID: 1010-6 <br /> Affoarda-Test <br /> 416 tad Street Designated Operator <br /> Galt,Ca 95632 Monthly Inspection Checklist <br /> 209-744-0112 Fax 209-744-0116 <br /> Site: CD& R CJ S CHEVRON Date: 5/19/16 <br /> 7501 W X 1T" ST <br /> TRACY,CA 95304 <br /> ❑Zane A.Nimmo ❑David A.'Winkler ❑Felix G.Ramirez Edward Stearns <br /> #5263322 #5263373 #5273934 #5250492 <br /> X= cs N=n NA=n to cable <br /> MOMMORNG PANEL/ALARM L[STORY Y N I NA. <br /> Monitoring system is powered on and in proper operating mode. X <br /> Monitoring system is not currently showing any alarms or warwngs. X <br /> Alarm history report/log for the previous mouth is available,and has been reviewed by the Designated UST X <br /> Operator. Attach a copy o the alarm history reportllog to this orm ' available.) <br /> Each alarm for the previous month has been responded to appropriately X <br /> Sensors located in tamp-top containment sumps have sot alarmed in the past month. X <br /> List all tank-top sumps where alarms occurred in the past month: <br /> Note.-Sumps where ars alarm has occurred In the past month must be inspected unless a qualified service technician responded to,and,properly <br /> addressed the cause of the alarm.Attach documentation verifying appropriate service to this report.if sump inspection is required record results in <br /> item 6,below. <br /> AST SYSTEM INSPECTION <br /> X N NA X N NA <br /> Tank-top containment stumps are free of water,debris,and hazardous substance.Sensors are located properly. <br /> Note: NX4 inspection qjrsumps is only required to s where an alarm has occurred in thepastmonthforwhich there is no service record. <br /> Sump Locarion:87 X Sump Location: <br /> Sump Location:91 X Sump Location: <br /> Sump Location:DlE X Sump Location: <br /> S ill containment structures are free of water,debris,&hazardous substance. <br /> Tank 1—Regular X Tank 5— <br /> Tank 2—Plus X Tank 6- <br /> Tank 3-Premium X 'tank 7- <br /> Tank 4-Diesel X Tank 8- <br /> Under-dispenser containment free of water debris,&hazardous substance.Sensors located properly- <br /> Dispenser <br /> ro erl _Dispenser 1/2 X Dispenser 19/20 X <br /> Dispenser 3/4 X Dispenser 21 X <br /> Dispenser 5/6 X Dispenser 22/21 X <br /> Dispenser 7/8 X Dispenser23/22 X <br /> Dispenser 9/10 X Dispenser 24/23 X <br /> Dispenser 11/12 X Dispenser 25/24 X <br /> Dispenser 13/14 X Dispenser 26/25 X <br /> Dispenser 15/16 X Dispenser 27/26 Satellite X <br /> Dispenser 17/18 X Dispenser 27 X <br />