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0 9 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Pacilily Name: COSTCO 1031 <br />Date: 09/06/2016 <br />Pacilily Address: 2440 Daniels St. <br />NA <br />City: Manteca <br />Zip Code: 95336 <br />Designated UST Operator Conducting the Inspection: Kaylynn Rummell <br />International Code Council Certification #: 8456633 <br />Expiration Date: 6/15/2018 <br />Signature: VNPhone: <br />(949) 460-5200 <br />(/ Y=Yes, N- No, NA a Not Applicable <br />Item <br />MONITORING PANEL/ ALARM HISTORY <br />Y I N <br />NA <br />1 <br />Monitoring System is powered on and in proper operating mode <br />X <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />X <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the Designated UST <br />Operator. (Attach a copy of the alarm history report/log to this form if available.) <br />X <br />4 <br />Bach alarm for the previous month has been responded to appropriately. <br />X X <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />X <br />5a <br />- List all tank -lop sumps where alarms occurred in the past month: <br />All tank -top sumps. <br />Note: Sumps where an alarm has occurred in the part month mart lee inspected unless a qualified service technician responded <br />addrcsaed, the cause of the alarm. Atrach documentation verifying appropriate service to this report. /fsump inspection is required, <br />in item 6, below. <br />io, and properly <br />record results <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Nntr Vaunt imar{nlMl n/n�mm /s onlvrrwurAln rumps whore an a/arm Far enured (n rhrlwl month (or which then it no arrWre rremt <br />Y N <br />Y N <br />Sump Location: W^ <br />Sump Location: "A <br />Sunip Location: ''a" <br />Sump Location: "I^ <br />Sump Location: "a^ <br />Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N INAI <br />Y N INA, <br />Tank -87W X Tank -91 <br />X <br />Tank -87E X Tank -additive <br />X <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors arc located properly. <br />Y N NA <br />Y N INA <br />Dispenser -1/1 X Dispenser -9/10 <br />X <br />Dispenser -3/4 X Dispenser -11/11 <br />X <br />Dispenser -5/6 X Dispenser -13/14 <br />X <br />Dispetuer-7/8 X Dispenser -15/16 <br />X <br />PAPERWORK INSPECTION Y N NA DATE <br />9 <br />Monitoring system certification has been completed within past 12 months. X <br />8/18/16 <br />10 <br />Secondary containment tests have been completed within the required timeframe. X <br />N/A <br />11 <br />Spill containment structure (bucket) testing was completed within the past year. X <br />8/18/16 <br />12 <br />Tank tightness testing was completed within required timefrume. X <br />NIA <br />13 <br />Line tightness testing was completed within required timeframe. X <br />NIA <br />14 <br />Other required testing/maintenance was completed within required timeframe. (List test/maimcnance items below) <br />TesiJMaintenance: X <br />Test/Maintenance: X <br />Test/Maintenance: X <br />FACILITY EMPLOYEE TRAINING <br />Y I N INA <br />I S <br />All facility employees have received the required on-the-job training within the past yeas <br />X <br />16 <br />All facility employees hired within the past 30 days have received the required on -the job training. <br />X <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require follow-up <br />action. <br />Page I of 2 <br />Yr <br />