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Site ID: 1010-6 <br /> Afforda-Te$t <br /> 416 211 Street Designated Operator <br /> Galt, Ca 95632 Monthly Inspection Checklist <br /> 209-744-0112 Fax 209-744-0116 <br /> Site: CJ's CHEVRON Date: 12-16-15 <br /> 11TH STREET <br /> .TRACY CA CA 95304 <br /> ❑Zane A.Nimmo ®David A.Winkler ❑ Felix G.Ramirez ❑ Edward Stearns <br /> #5263322 #5263373 #5273934 #5250492 <br /> Y= es N=no NA=not appticable <br /> MONITORING PANEL/ALARM HISTORY Y N NA <br /> Monitoring system is powered on and in proper operating mode. X <br /> Monitoring system is not currently showing any alarms or warnings. X <br /> Alarm history report/log for the previous month is available,and has been reviewed by the Designated UST X <br /> Operator. (Attach a copy of the alarm history report/logreporillog to thisform i available. <br /> Each alarm for the previous month has been responded to appropriately X <br /> Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> List all tank-top sumps where alarms occurred in the past month: <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and properly <br /> addressed, the cause o/'the alarm.Attach documentation verifying appropriate service to this report.1j'sump inspection is required, record results <br /> in item 6, below. <br /> AST SYSTEM INSPECTION <br /> Y I N I NA I I Y I N NA <br /> Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note: Visual inspection of sumps Ls only required in sum .s where an alarm has occurred in the past month for which there Ls no service record. <br /> Sump Location:87 X Sump Location: <br /> Sump Location:91 X Sump Location: <br /> Sump Location:DSL X Sump Location: <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> Spill containment structures are free of water,debris,&hazardous substance. <br /> Tank 1—Regular X Tank 5- <br /> Tank 2—Plus 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 1/2 X Dispenser 19/20 <br /> Dispenser 3/4 X Dispenser 21 <br /> Dispenser 5/6 X Dispenser 22/21 <br /> Dispenser 7/8 X Dispenser23/22 <br /> Dispenser 9/10 Dispenser 24/23 <br /> Dispenser 11/12 Dispenser 25/24 <br /> Dispenser 13/14 Dispenser 26/25 <br /> Dispenser 15/16 Dispenser 27/26 Satellite <br /> Dispenser 17/18 Dispenser 27 <br />