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0 0 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />'Facility Name; Chevron #1141hate: ` r <br />Facility Add VZ 114 e5 <br />Ci , Zi Code. <br />Desi ted US ST O crato Conductin the !ns ectian: John D I <br />International Code C nci ificatio 80 863 L.x iration Date: 11124.12011 <br />5i nature; Phone; 916-217-1373 <br />='Yes, N - No, NA = Not A licable <br />Item D G PANEL/ ALARM HISTORY Y NA <br />l Monitorin sY stern is powered on and in proper operatin mode- <br />2 Monitorin s stem is not currentl shawin an alarms ur wwaribn s- <br />3 Alum history report/log for the previous month is available, and has been reviewed by the <br />Designated UST c?l�erator. (I ttcr�h a co ° r� the alarm histo re UrtIJD to this arm f available. <br />4 Each alarm for the previous month has been responded to appropriately- <br />5 <br />ro riatel - <br />5 Sensors located in Eank-tup containment sum shave not alarmed in the ast month. , f <br />5a - Lisr all tank-top sura s where alarms cccArreld in the past m6nth: •' ��%� � <br />Note: Sumps where an alarm has occurred in the least month must he inspected unless a qualOed servics technician responded to, and <br />propBYty addressed, the Cause of rhe Olam Arach doosonehtatton ver!&irg appropriate service to this report, <br />sum ms ec".on is Ye' iced record resu'trs in item 6, below. <br />UST SYSTEM INSPECTION <br />6 Tank-top containment sumps are free ofNvater, debris, and hazardous substance. Sensors are located properly. <br />NOW: Vj.=i mptetioh o sumps is uni re ii-ad in sum s where an alarm has o-vurred in rbep est inoreth far which there is no service record. <br />Y N <br />Sim .Location: 87#1 4 Sump Location: 91 <br />Sum Location: 87#2 i " Sumo Location: Diesel <br />Sum Locations: 89 hum Location: <br />7 S ill containment structures are free of water, debris, and hazardous substance. Y N NA <br />'Y' NA <br />Tank I - Contents 7 1 Tank 3 - Contents: 89 0 <br />Tank 2 - Canrants: 7#l2 vw 89 Tank 4 - Contents: 91 or Diesel <br />8 ilnder-dis enser containment areas are free of water, debris, and hazardous substance. Sensors are IocateYd r 1NA <br />Y' N NA <br />Denser 1 I'2 Dis enser 11 / 12 <br />Dis enser 3 / 4 Di s enser 13114 <br />DIS enser 5 / 6 INS eraser 15 / 16 <br />Dis enser 7 /8 Dispenser 17/18 <br />Ais enser 9; 10 Dis enser 1Q'20 <br />PAPERvvoRK INSPECTION Y N NA40 <br />I}ATE HONE <br />9 Monitoring system certification has heera corn feted within est 12 months. <br />10 Secondary containment tests have been cam leted within the re aired timeframe. <br />11 S ill containment structure bucket testin was cam feted within the est ear. <br />l2 Tank ti lane- testin was con feted within rc nircd timefrarme. <br />13 Line tightness testing was cornleted within re aired ttirmefranse. <br />14 +Other re uirzd testin maintenance uvea co feted within re ' ed timeframe. tit testimaintenance items below- <br />TeskA4aintenarnce: LLD testin was co feted within the re uired tiinefrarne <br />1`est/Malntenance: <br />TestlUa tenance: <br />FACILITY' EMPLOYEE TItAiN [NG Y N NA <br />15 All facili ernplo ees have received the re uired on-the-job training within the past ear. <br />_ 16 All facility employees hired within the past 34 days have received the re aired. on-me-jou trAinui <br />Note: Any answer of"N" should be explained in the comment section on the following page, and will require <br />follow-up action. 1 <br />Page 1 of 2 November 2004 <br />.J <br />LT/CT 39dd VILTISO 8VT066S-6132 Eb:Lo T10Z/EZ/Z0 <br />