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Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Rancho San Miguel I Date:09/13/16 <br /> Facility Address:610 Cherokee Lane <br /> City: Lodi Zip Code:95340 <br /> Designated UST Operator Conducting the Inspection: Karen R Arnaiz <br /> International Code Council Certification#; 8032295-UCEx iration Date: 05/05/17 <br /> Signature: Phone:(209 518-4836 <br /> Y=Yes,N—No,NA-Not Applicable S <br /> Imo.. . ... ... MONITORING PANEL/ALARM HISTORY Y . N NA <br /> 7V Monitoring` s stem is owered ori end m ro r o eratin"mode. X <br /> 2 Monitoring system is not currently showing any alarms or warnings. X <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the X <br /> Designated UST Operator. Attach a copy of the alarm history reporillog to thisform i'available. <br /> 4 Each alarm for the previous month has been responded to appropriately. X <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> 5a List all tank-top sumps where alarms occurred in the past month <br /> Note:Sumps inhere on alarm lws occurred in rhe pwr month must be inspected unless a qualtrwd.service techricimr responded to,mxl <br /> properly addressed,the cause of the alarw.Attach documentation rertj)7ng approp nate service to this report. <br /> mom It'stanp inspection is reaired,record results in tienu 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual hj coon o amu Is an re tubed in sun where ah ahuvn Ira,omurred in the sl n onth or which there is no serviceimcord <br /> Y N Y N <br /> Sum Location:87 Fill X Sam Location:9! Turbine X <br /> Sum Location:87 Turbine X o <br /> Sump Location:91 Fill I X <br /> 7 Spill containment structures are flee of water,debt end hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1 —Contents: 87 X <br /> Tank 2—Contents: 91 Ix I I I I I Ig <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located properly. €€! <br /> Y N NA I Y I N I NA <br /> Dispenser 1/2 X I I I It <br /> Dispenser 3/4 X <br /> Dispenser 5/6 X <br /> PAPERWORK INSPECTION y Y N INA I DATE DONE € <br /> 9 Monitoring system certification has been completed within past 12 months. X 10/26/15 <br /> 10 Secondary containment tests have been completed within the required timeframe. X 08/26/16 <br /> 11 S ill containment structure(bucket)testing was completed within the past year. X 1026/15 <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line tightness testing was completed within required timeframe. <br /> 14 Other required testing/maintenance was completed within required timeframe. List test/maintenance items below. <br /> Test/Maintenanee: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> mmiammigbiii mammal, <br /> FACILITY EMPLOYEE TRAINING Y~ N �NA <br /> 15 All facili em to ees have received the required on-the-job trainingwithin the past ear.05/04/16 X <br /> 16 All facili em to ees hired within the past 30 days have received the re uired on-the 'ob trainin . X ; <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action. k <br /> P <br /> i <br /> k <br /> s <br /> °s <br /> Page 1 of 2 November 2004 g� <br /> I <br />