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• • � <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facilit Nanie_ 11 Date: <br /> Facilit Address: <br /> City- Zip Code: <br /> Valley Underground Tank Monitoring <br /> Mailing and Refnittance Address: Valley Underground Tank Monitoring <br /> P.O. Box 91 <br /> Stockton, CA 95201 <br /> ote i neted UST O erator Conducting the Inspection: <br /> 1CC Cerrif . ae 4 Ex iration Date: <br /> Sit nature Q Phone: 20 _ <br /> Y=Yes, N=No, NA=Not Applicable <br /> Itern �� _ Monitorin Panel!Atarm Histo Y N NA <br /> 1 MoriitorinJ system is pow re on an in proper operating mo e. <br /> 1 of inuring system is not current y s owing any alarms or warnings. <br /> afro istaiy repo og ort a previous month Is awaildule,ano nas been,reviewed <br /> i <br /> by the Designated UST Operator. (Attach a copy of the alarm hisiory report/109 if available). <br /> 4 !-vz a u arm or-t e previous Mont as been respon e to appropriate y. <br /> ensors oca ain tan -top onmumnave not alarmed in the pas mon <br /> a +1 sl a tan --top sumps w ere a arms occurre In t e past mont <br /> Nolu. Sun fps Whore an alawn has oCcLffned in the past monlh must be inspected unless a qualified service <br /> luchniciuri wsponded to, and properly addressed, the cause of the alarm. ,attach documentation verifying <br /> appropri-We service to this report. If sump inspection is required,record resulls in ileal 6, below. <br /> UST System Inspection <br /> n -top containment sumps are ree o water, ens,an azar ous su stance. <br /> Sensors are located properly. Nate:Visual inspection of sumps are only required <br /> s,....y,.% wl olt: an alarm has occurred in the pas(month for which there is no service record <br /> lens, <br /> - o <br /> ump ocation: ump ocation: <br /> Zjurrs ocation: ump ocation: <br /> ump occatiOuv ump ocation:pi containment structures are ree owathazardous substance. <br /> Tank - ontents: r an - ontents: <br /> T_an -- ontents: an 4-Contents- <br /> --IF <br /> Cinder- ispenser containment areas are ree o water, a ris,an azar ous su stance. ensors <br /> aie located property <br /> Dispenser 1/2 Dispenser 9/10 <br /> .Dispenser Dispenser 11112 <br /> ispenser / Ispenser <br /> len enser Uspenser 106 <br /> Paperwork Inspection Y N NA <br /> ondonng system certification has 6een completed wit in past 12 months. <br /> —WSecondarX containment tests have been completed within reqoired time rame/ <br /> Spill containment structure (bucket)testing was completed within past year. r <br /> 72-Tank tightness testing was compete wit in require Ume fames. <br /> ine tightness testing was completed wit in required lime fame. <br /> CS er requtre es ing main enance was completed within required Yimetrarne. (List maint. ite,ris below). <br /> est maintenance. <br /> est mainienance: <br /> es maintenance: <br /> Facility Employee Training YIN NA <br /> 15 All fac ity employees have received the require on-t a-lo (raining in I e past year. <br /> 3 facility employees hired within ta past 30 days have receive the require <br /> un-Ihe-ob training. <br /> Mote= Any answer of "N" should be explained in the comment section on the following page, <br /> and will require follow-up action. <br /> Pg, 1 of 2 <br />