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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name'. n I ./ — , Date: /_ <br /> Facility Ad rens: <br /> Cit ,�'� - +� Zip Code: <br /> Valley Underground Tank Monitoring <br /> Mailing and Remittance Address: Valley Underground Tank Monitoring <br /> P:O, Box 91 <br /> _ Stockton, CA 95201 <br /> Desi naled UST Oj2erator Conducting the InsLection: t- <br /> 7 CC C e r t i f j,c a XX Ex iration ®ate: _ <br /> Si nature: / Phone: 209-649-8956 <br /> Y=Yes, N=No, NA=rout Applicable <br /> M <br /> Monitoring,Panel/Alarm History Y N NA <br /> Monitoring system is powere on an in proper operatin mo o. <br /> aririorli ig system is not currently showing any alarms or warnings. <br /> dim hi5toiy reporulog fort the previous month is available,anas been reviewe <br /> by the Designated UST Operator.(Attach a copy of the alarm history repoiViog if available). V <br /> 4 dt t is arm ort a previous montTi has been responded o appropriately. <br /> sensors IoE5163 in tank-top containment sumps avof-aTarmed in the past mon , <br /> a est a tan -top sumps w area arms occurredInt the past month: F y^._� <br /> !Vote.- Ships where an alarrrr has oCcu►red in the past month must be inspected unie-ss a qualified servic e <br /> technwiari responded to, and prnparly addressed,Me cause of the alarm. Attach documentation venfying <br /> appropritjr&service io ujis report. if sump inspection ismquired,record results in item ti, below. <br /> =� UST System Inspection <br /> arc-top containment sumps are ree ot water,debris.and hazardous su stance. <br /> Sensors are.iocate[i property. Nole:l/isuai inspection of sumps-are only required <br /> i n s4. p5 wl iere an alarm has occunw in the past month for which Ihefe is no Service record <br /> SumpLocation: SumpLocation: <br /> ouRi ocation: ump ocatron: <br /> ump ocatron: eum Location: <br /> N NA <br /> water <br /> pi containment structures are ree o , ns,an hazardous substance. <br /> an - ontents: n . - ontents: <br /> `l an ontents: an 4- ontents: <br /> CJntl—er- ispenser con inment areas are ree o water, a ns,and hazardous su stance. ensors <br /> are located properly. <br /> a <br /> LDispenser ispenser <br /> 9116 <br /> Dispenser ispenser i' <br /> Dispenser �,_ Dispenser 4 / <br /> Ms enser 7 .11 U-Spe—Ese r_T51 16f' <br /> Paperwork Inspection I Y I N J NA <br /> anitorint� system cert! rcatlon has been completed within past 12 months. <br /> Secan a containment tests have been completed within required time fame. <br /> spill containment structure uc et testing was completed within past year- <br /> IT <br /> an tig tress testrn was camp ete wit in requtfe lime fames_ <br /> Line tightness testing was complett:u completewithin ieclu,,R timeframe. <br /> Other require ired timetrarne. (List maim_ items below). <br /> es maintenance: <br /> est�intenance: <br /> es niaintenance: <br /> r _ Facill1tv Errto ee Training Y N NA <br /> v iTci dy emp ogees have received the require on-1e-to training in the past year. 1 <br /> c+i,ty emp ogees ire wit in t e past ays have receive t require <br /> orvlhe-ob ►!airing. <br /> Note: Any answer of "N" should he explained in the comment section on the following page, <br /> and will require follow-up action. <br /> Pg. 1'pf 2 <br />