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Designated Underground Storage Tank (UST) Operator <br />Manth1v Vis" Inspection Checklist <br />Iz=-lkyNAmv-2jQ 771I]aote <br />- <br />Fadfity Address: <br />..°erect <br />1 <br />Zai Code. <br />Dm ted UST r Co the n. John Daley <br />MT#Wm $STb"kC ! is not Shp alp oY <br />International gACSP50 Certifications # X0013863 - CIC <br />Expj7#9,� r�aie: November 2.4, ,201.1 <br />Si <br />Phone:( 916 )217-I373 <br />Item <br />1At0MT0AZMG Pte. /ALARM HISTORY Y N NA <br />' <br />..°erect <br />1 <br />M*Afis on end in mode. <br />2 <br />MT#Wm $STb"kC ! is not Shp alp oY <br />3 <br />Alarm history report/log for the pruvioos mondh is availablc, and leas been rcvimed try dse <br />Desi UST or_ 4ttank aeopyof0w alarm kistmy re rtgo to this orm i available.) <br />4 <br />Each niaim ibr the prnimw niortth has be= mVonukd to <br />S <br />Senwi-s 1oanod m tan 4Dp contaimsnrni sumps have not alarmed in the vast month. <br />5a <br />all tank -lop sumps where alarms occurred in the past mnlh: - - -/o 1 ter 'rPd <br />Nate: sumps where an alarm has c ccurred in Abe parr momh must be rurPesa a gw kfled service rechrackm Desponded to. and -574,w, <br />Properly addressed the cs rse of tlia alarm. dila ch dacum=id& w vong5oft gprVHCie S -WP a io this igwrL <br />cum yr on is red record ran)& hr r%m 6, befov. <br />VST SYSTEM YNSPECTTON <br />6 <br />Tank -top bontain�t sumps are fmo of water, debris, and Mardous submanc, Sensors are located properly, <br />Note: Vrsua! tn: dew ru»7 s is red in a where an clanm boli occurred in the st mowEir which there is no service record <br />Yi r;4a1 <br />8791 SnSm <br />> i.. ° a., <br />SW" Locatrrnr. Diewl "+3• <br />Sum Location. 89 <br />Sump Location: S=M Location: <br />7 <br />Spill cortMunent Mumm are free of water, dcnis, and ham does sebsta[lce- _ <br />Y NA Y N IIIA <br />Tank I - Contents, 91 Ta* 3 - C-anienU, 87 <br />Tank 2 - Contenis 89 ' Tank 4 - C:ontenir Diesel , <br />& <br />eonminn=t am at free ol water debris, and huardous subsiunee. Sensors bre 1 ed <br />-Under-&qmsex <br />Y: N NA it N NA <br />Dispenser I /2 Dia nser 9 / 10 <br />Dispenser 8 / 4 pl nser 11 / 12 <br />Di S/6 Di r13/14 ^� <br />Dispenser 7/& Liawnsrer 15/ 16 <br />PAPIKRWORK INSPECTION Y 0,N NA DATE HONE <br />9 1V1onitormg system a J—ffication has been completed within 12 mouths, – - <br />14 Suri conta,nme t tests have been min feted within the regufted timdrame. = �– <br />11 Spill cmtahwxnt stmt (bwJmt) tes"S was cumpksed w¢thm the paqyt r_ -- ° <br />12 Tank tightwss t letsed within fimcftam& <br />13 Line ti ss testing wo& convIeW within required te. <br />14 Other roquiredtestin wait nance was completcd within required timd mr. (List I vt!jgntentmce sterns bolo!. <br />Text/Maintenance. Leak Detection <br />TestlMainMnartce: <br />Test/A�aixienartce: <br />, c � . a. a„ • ,;,• - , � . �- ,m�.... �, . � ,: .. a .> : in<:,h,3r .n un'.�-.., d:� l4n:k'+r%s{y:+'r. <br />JlACHATTY EMPLOYEE T14i.4J;XWG I Y I N I NA <br />15 1 Mbfifi& esnnlov+ees have received the required on-the-job trmmg within the past: year ... ._..__.... .... _. . <br />[16 1 AH facilityemployees hired within the past 30 days have received the required on-the-job trainiu l <br />Note: Any answer of "N" should be exidAwd in the mmmeiat section on the following page, and will require <br />follow-up scam <br />Page t of 2 November 2004 <br />LTIVO 39Vd VTLTISS OPT066S-60Z Eb:LO TTOZ/EZ/ZO <br />