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'-.1 <br />0 0 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly 'V'isual Inspection Checklist <br />Facility Nam , Chevron # batt: ti <br />Facili 4ddress: /L c <br />Ci!y: Zip Code: <br />Desi natal ST Q erator Cola lucting the Inspection: Edward Dahl n <br />International Coda Coupai l Cgtifiwion. 416984 -UC Ex iratian date: 09 /28/2012 <br />Signature: _ phone: L 916 271-2363 <br />Y Yes N = No, NA - Not A 11cable <br />Item A10N1x0R1NG PA " EL / A1.AIt1'vii 111ST0RY Y N NA <br />1 Monituxing s ystcm is powered on and in proper operating mode. <br />2 Monitoring stem is not currentl showing any alarms or v.-wnings. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Desi ated UST Operator, Attach a copy of the charm history r2orft to thisform i available.) <br />4 Each alarm for the provious month has been responded to t1ppropnately, <br />5 Sensors located in ta,k-top containment sumps have not alarmed in the ast month. <br />5a List all tank- top sumps where alarms occurred in the past month: <br />hare: Sum17s where an alarm has occurred M A past aronih narst be insp;creru&ss a qual!fied service rechriidarr responded to—,and <br />property addres$ed, rhe cause of rhe alarm. Aftath doaumontotion verr&irg apprpprittia soice to this report. <br />ffsump ins ectiQn is r€ uirj, rico; d resrttts in item 6, below. <br />UST SYSTEM INSPECTION <br />51 Tank -top containment sumps are frcc of water, debris, and hazardous substance. Sensors are located properly. <br />Note: ;76W01 ins eCtill, v sum t i t ori required in SttmpS WhEre pn alarm i riF nccurred in the aw month e r ja h B----._-� <br />bum Location; 87#1 <br />Sum Location.' 87#2 <br />Sum Location: 89 <br />7 Spill containment structures are free of water <br />V <br />Tank 1 - Contents.- 87#1 <br />Tank 2 - Contents: 87#2 or 89 <br />$ —Under—dispenser Containment areas are free o <br />112 <br />314 <br />5/6_ <br />7/8 <br />9/10 <br />W <br />PAPER OF <br />9 Monitoringsystem certification has beat earn 1 <br />10 Sccond containment tests have been Com ret <br />11 <br />Spill containment structure ucket testin was <br />12 Tank ti fitness testin was convicted within req <br />13 bine tightness testingwas com lei <br />ted within re <br />14 Other required testi; i xlaaintenanntee was colel <br />Test/hfaihtenance: LLT) testing was com 1 <br />- Test/Matirtenance: <br />w :c sere ti no se"Mc, <br />Y 1 <br />Sum Loeatiort: <br />91 <br />1. um Location,, Diesel <br />Sume Location: <br />and hazardous substance. <br />NA Y p <br />'Tank 3 - Contents: 89 or 1 Ae <br />Tank 4 - Contents; 91 or Dieeed <br />debris and hawdous substance, Sensors are located Dra <br />NA Y P <br />Dis enser 11112 <br />Dienser 13 114 <br />Dfs enser 1 S / 16 <br />Dispenser 17/18 <br />Dispenser 1900 <br />NA <br />NA <br />Harr —IMN Y N NA DATE DONE <br />within past 12 months. <br />ithin the required timeframe. <br />leted within the past vear. , r <br />I timeframe. <br />timeframe. <br />,ithin required timeframe. List testlmai ante it --Fm below_ <br />within the required tirne€rame- <br />FAG'ILl'1 Y Ell1PL0YEE TRAINING' Y N NA <br />15 -All facility em to ees have received the require <br />d an -the -`ab training within the ast year. <br />16 All facili emtrlo ees hired within the past 30 days have received the re wired on-the-'ob trainia <br />Note: Any answer of "N" 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 />5Tltr0 39Vd VTLTISD 8VTO669-60Z VC:LO TTOZ/8Z/ZO <br />