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%fa in- lnin_r, <br />Afforda-Te$t Designated Operator <br />416 2"d Street g p <br />Galt, Ca 95632 Monthly Inspection Checklist <br />209-744-0112 Fax 209-744-0116 <br />Site: C D & R - C J's CHEVRON Date: 11/6/2015 <br />7501 W. 11 th STREET <br />TRACY , CA 95304 <br />❑ Lyle D. Nimmo ® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez <br />#5249115 #5263322 #5263373 #5273934 <br />Signature: <br />MONITORING PANEL / ALARM HISTORY <br />Y <br />N <br />NA <br />Monitoring system is powered on and in proper operating mode. <br />X <br />Monitoring system is not currently showing any alarms or warnings. <br />X <br />Alarm history report/log for the previous month is available, and has been reviewed by the Designated UST <br />Operator. Attach a copy of the alarm history report/logreportllog to thisform if available. <br />X <br />Each alarm for the previous month has been responded to appropriately <br />X <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />X <br />List all tank -top sumps where alarms occurred in the past month.- <br />onth:Note: Sumps where an alarm hqs occurred in the past month must be inspected unless a qualified service technician responded to, and properly <br />Note: <br />addressed, the cause of the alarm. Attach documentation verifying appropriate set -vice to this report. !f 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 <br />NA <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection of sumps is only required in sum s where an alarm has occurred in the past month for which there is no service record. <br />Sump Location: 87 STP X Sump Location: <br />Sump Location: 91 STP X Sump Location: <br />Sump Location: DIESEL STP X Sump Location: <br />Sump Location: Sump Location: <br />Sump Location: Sump Location: <br />�jl <br />Spill 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 1/2 X Dispenser 19/20 <br />X <br />Dispenser 3/4 X Dispenser 21 <br />X <br />Dispenser 5/6 X Dispenser 22/21 <br />X <br />Dispenser 7/8 X Dispenser 23/22 <br />X <br />Dispenser 9/10 X Dispenser 24/23 <br />X <br />Dispenser 11/12 X Dispenser 25/24 <br />X <br />Dispenser 13/14 X Dispenser 26/25 <br />X <br />Dispenser 15/16 X Dispenser 27/26 Satellite <br />X <br />Dispenser 17/18 X Dispenser 27 <br />X <br />