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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facilit Nan-le: n n t r t .' ,^y Date: / n <br /> -- Fablit Address: <br /> Cit <br /> Valley Underground Tank Monitoring <br /> Nlailing and Remittance Address: Valley Underground Tank Monitoring <br /> P.O. Box 91 <br /> Stockton, CA 95201 <br /> Desi Hated UST O erator Conducting the Inspection: ' -1 n P 0 TW <br /> ICC Certif.ic.a XX4141012575 lExpiration Date: <br /> 5i nature: shone: 2 _ _ <br /> 89 <br /> Y=Yes, N=No, NA=Not AGplicable <br /> KCOni'fo_r'�n_osysiem <br /> Monitorin ,Panell Alarm Histo Y N NA <br /> is powere bn an in proper operating mode. v <br /> uoiloring system is not current y s owing any alarms or warnings. <br /> arm history reporujag fort the previous month is available,and has been reviewe <br /> by the Designated UST Operator.(Attach a copy of the alarm history reporoog if avaiiabie). v <br /> 4 rac a a arm3r the previous month as been responded to approprrafe y. <br /> 5 Sensors located in tank-top containment sumps have not alarmed in a-pas--mon . 4- <br /> a List all tank-top sumps where alarms occurred in t e pa§tmon : <br /> Nolo: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service <br /> fachnivian tdspvnded to, and properly addressed,the cause'bf.,the alani' Attach dpwiif entation ventying <br /> w <br /> atrpjopriete seniice to this report- If sump inspection is required, sul2s in item 6,'bsbw. <br /> n -top containment sumps are tree oSwa er; a ns,an azar ous substance <br /> ( i _ ern Ins .ectid <br /> : <br /> SrAssurs are located property. Nole Visual inspection of sumps are only,required <br /> ii)s",1p-s wl ujrr_-an alarm has occurred in the past month for which there is no service record <br /> SumpLocation: SumpLocation: <br /> um ocatlon: ump Location. <br /> urnpLocation: um Location: <br /> er,pi containment structures are free, azar ous <br /> substance. <br /> Tank - ontents: fJree <br /> an -Contents.- <br /> 'i an 1 ontents: (� an 4 ontents: y- <br /> �r=- Ispenser containment areas are o,water,debris.and hazardous substance. ensors <br /> are located properly. - <br /> _D /2 - v ispenser <br /> Dispenser 3/4 penser 11112 <br /> IsperlS� is enser 19114 Dispenser :1 Dispenser 15/16 <br /> Paperwork Inspection Y N NA <br /> onitoring system certification has been compete wit to past —months. ✓ <br /> econ a containment tests Eave Seen completed within requ;rea timeframe. L. <br /> Spill containment structure (Bucket)testing was completed within past year- <br /> TT Tank tightness testing was completed within required tune fames. <br /> in tig tness testing was completed within required timeframe. <br /> er required testing/maintenance was completed within requ—ired rimetrame. (List maint. items below}- <br /> es maintenance: <br /> Te-siTm`aintenance: <br /> es niainlenance: <br /> / <br /> Facility Em to ee Training Y N NA <br /> _. Ffaci ity employees have receive the require on-t e- training in t e past year. <br /> _TE All aci it—employees hiFea wit in t e past 30 days have received the require <br /> an-Itie-ob gaining. <br /> Note: Any answer of"N" should be explained in the comment section on the following page, <br /> and will require follow-up action. <br /> Pg. f of 2 <br />