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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> 'J Fucifit Nan le: 1. ' Date: <br /> Facility Address: r ,� <br /> Zip Code: r' <br /> Valley Underground Tank Monitoring <br /> Mailing and Remittance Address: Valley Underground Tank KlIonitoring <br /> P.O. Box 91 <br /> _ Stockton, CA 95201 <br /> Dt:sj noted UST O erator Conducting the Inspection: r'� /1 i c f ` /I-_ 'T� <br /> ICC CertifAcqte# XX4 1 Ex iration Date: 11-13-200 <br /> Sir nature i ( , jPhone: 209-649-8956 <br /> Y=Yes, N=No, NA=Nut Applicable <br /> ]teM <br /> rn _ MonitoringPanell Alarm Histo Y N NA <br /> 1 anitorrng system is powered on and in proper operating mo e. <br /> 1 or ilei ing system Is not currently s owing any alarms or warnings. e. <br /> arm hizitury repcirvlog tort the previous month is available.and has been reviewed <br /> by the Designated UST Operator. (Attach a copy of the alarm history reportAog if available). y� <br /> 4 the previous mon-th has Been responded to appropriately. <br /> 5 Sensors located in lank-top containment sumps have not alarmed in the past month. <br /> a List all tank-top sumps where alarms occurred in the past moat : o lr� i")1- <br /> NOW. Sumps wlrere an aiarrit has oCcu►red in the past Mrillh must be inspected unless a qualified service <br /> ivclrniciUn responded to, and proparly addressed,the cause of Me alarm. Attach documentation verifying <br /> a propritJte service to this report_ if sump inspection is required,record results in item 6, below. <br /> r�g UST System Inspection <br /> n -top containment sumps are ree ot water,debris,and hazardous su stancye_ <br /> Sensors are located properly. Note:lrisrJal inspection of sumps are only required <br /> i rf.SL.:,ps wt tore an "farm has occurred in the pas(month for*which there is no service record <br /> ump ocatron: ,� ump Location: <br /> 'Surri Location: Sump Location: <br /> ump Location: um ocatron: <br /> rii containment structures are free o water,• a ns,an azar ous substance. <br /> an -Conlentsi <br /> Tank'?- onlents: ITank 4Contents: <br /> n er- rspenser containment areas are tree of water,debris, and hazardous su stanr_,e. ensors <br /> ore located f2roperly. <br /> Dispenser IT2- Dispenser 9110 �- <br /> rspenser rSpenser <br /> ishenser -Spenser 4 <br /> is en5er 718Dispenser 15116 ' <br /> Paperwork inspection Y N NA <br /> onrionny systemcerti rcation has been completed within past 12 months. v' <br /> 'tb Secon a containment tests have been completed wit in requare time tame. <br /> Spill containment structure (bucket)testing was completed within past year. <br /> 12 Tank lightness lestinQ was completed within required timeframes. <br /> Line tightness testing was completed within—req--uirea limeframe. <br /> er require es rng main enance was comp e e wi in require ime rame. is main. items below}. <br /> est maintenance: <br /> est maintenance: <br /> es niaintenance: <br /> Facility Employee Training Y N NA <br /> i Taci ity emp oyees have received the require on-the-job training in t e past year- <br /> Iro JAI[ <br /> facility employees hirea within t e past 30 days Tiave received the require <br /> orgl -ob training. <br /> Note: Any answer of "N" should be explained in the commept section on the following page, <br /> and will require follow-up action. <br /> Pg. 1`pf 2 <br />