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1.100 <br /> s Designated Underground Storage Tank (UST) Op IRFCEIVED <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Rancho San Miguel Date:09/13/16 Noy 14 2016 <br /> Facility Address: 610 Cherokee Lane <br /> City: Lodi Zip Code: 95340 TH <br /> Designated UST Operator Conducting the Inspection:Karen R Arnaiz ENVIRON <br /> International Code Council Certification#: 8032295-UC Expiration Date: 05/05/17 nEPARTM <br /> Signature: Phone:(209) 5184836 <br /> Y=Va.N=No, A=NotApptimble <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> I Monitoring sgstem is pocketed on and in proper operating mode. X <br /> 2 Monitoring system is not currently showing any alarms or warnin s. 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 cea of the alarm histoa report/logreport1log to this.form if 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 where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> Ifsump inspection is required,record results in item 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 ins su <br /> inspection o ms is on re uired in sumps where an alarm has occurred in the t month or which there is no service record. <br /> Y N Y N <br /> Sum Location:87 Fill X Sum Location: 91 Turbine X <br /> Sum Location:87 Turbine X <br /> Sum Location: 91 Fill X <br /> 7 -Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank I —Contents:87 X <br /> Tank 2—Contents: 91 X <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Y N NA <br /> Tr <br /> -Dispenser 1/2 X _ <br /> Dispenser 3/4 X <br /> Dispenser 5/6 X <br /> PAPERWORK INSPECTION Y N 1 N.A DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. Xr 10/26/15 <br /> 10 Secondary containment tests have been completed within the required timeframe. X 08/26/16 <br /> 11 Spill containment structure(bucket)testing was completed within the ast ear. X 10/26/15 <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line tightness testing was completed within re uired timeframe. <br /> 14 Other required testing/maintenance was completed within required timeframe. List test maintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> NA <br /> FACILITY EMPLOYEE TRAINING TYTN NA <br /> 15 All facili em to ees have received the required on-the-job training within the past year.05/04/16 1 X <br /> 16 All faciliLy employees hired within the past 30 d2Zs have received the required on-the-job trainin X <br /> Note: Any answer of"M°should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Page 1 of 2 November 2004 <br />