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0 0 <br />Designated Underground Storage Tank (UST) Operator <br />Month y'V'isual Inspection Checklist <br />,rRF-Facirity Name: Chevron 4'M bate: /✓ <br />Facility Address: " P/1 <br />Ci : zip Code_ <br />Desi aced UST Operator Conducting the Ins ectton. John Dale <br />International Code CcsiDcil Certification: #8000863 Expiration Tate: 11/24/2011 <br />Si nntufe: <br />Phone: 916-217-1373 <br />Y = Yes N = No NA Not A licable <br />item G PANE X 1 ALARM HXSTORY Y N NA <br />1 M <br />onitoring System is novated on and in ro er o ratite mode. <br />2 rn is not currentlyshowingan alarms or warnings. <br />3 Alar report/log for the previous rnonth is available, and has been reviewed by the <br />Designated UST Operator- LAttach a copy a the alarr1log to this eirm if available. <br />4 Facb alarm for the previout month has been responded to appropriately. <br />5 Sensors located in tank -to containment sum shave pot alarttled in the est month. <br />5a _ List all tank -top sumps where alarms occurred in the past month: '" <br />yore Su raps where an alarm has �occwrred in the pass month must be inspected unless a qualified service techniaion resp d r©, and <br />properly addressed, the cause of thB alarm Attach documentation ver*ng appropriare 30rviee to this report, <br />t su irds eetlan rs required, record results in item 6, belmv. <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 snspection of sum_ s is on re. tred in Ju! S where an alarm }ws oxrorred in the past month or which theme is nod rntce.reeord <br />Y! N <br />Surn Location: 8701 <br />Sum Location: 91 } <br />Sump Location; 67#2 Sum Location: Diesel <br />Sum Location: 89 Sum Loeation.• <br />7 Spill containment structures are free of water,, debris and hazardous substance, _ <br />'� I N 11YA Y NA <br />Tank l - Contents: 87#1 3 - Cuntetus: 89 or <br />Taink. 2 - Contents: 87#2 or 89 Tank 4 -- Cnntenty, 91 pr Diesel <br />S Under -dispenser containffient areas are free of water, debris and hazardous substanoe- Sensors are located roN erl NA <br />Y N NA — <br />Dispenser 1 / 2 Dis eraser 11712 <br />Digs eraser 3 / 4 isDenser 13 / 14 <br />Dis eraser S / 6 Dispenser 15 / 16 <br />D' ' eraser 7/ 8 Dis enser 17/18 <br />Drs erns 14 Dis eraser 19120 <br />� '1VA . DATE pAPEit'4Vii�tK INSPECTION <br />9 Monitoring s stem certification bas been completed within ast 12 months- - <br />l0 Second cotrtainraent tests have been corn ectad within the re uired tirnefre. <br />l 1 Sill containment structure (bucket) testin vF as corfl leted within the past year- r <br />12 Tank ti fitness testitig was corn leted within required timeframe. <br />13 Line ti tress testing was corn feted within re uired timeframe-- <br />i4 Other .re uired testin ainteaance was com leted within re uired timeframe, List test* 'rttenance items below. <br />TestlMaintenance: LLD testirt was completed within the regarea tirnefrarne <br />T estlMatntenance: <br />TostaMaintenance: t <br />�. Y NNA <br />FACILITY EMPLOYEE TRAINING <br />15 All faciliry employeeshave received the re uired on-the-job training within the pastyear. <br />16 All faCili employees hired within the est 30 days have received the required on-the-job training. <br />Note. Any answer of "N" should be explained in the comment section on the following page, and will require <br />fullow-up action. <br />Page 1 of 2 November 2004 <br />LT/TT 39Vd bZLZISS OV1066S-6K 'IV :LO ZZOZ/£Z/ZO <br />