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7 � <br /> Designated Underground Storage Tank (LDS►T) Operator <br /> _ Monthly Visual Inspection Checklist <br /> Facility Nafne: Date: <br /> Ullt AddfeSS: <br /> City, f a/7 Zip Cade: <br /> Valley Underground Tank Monitoring <br /> Mailing and Remittance Address- Valley Underground Tank Monitoring <br /> P.O. Bax 91 <br /> _ Stockton, CA 95201 <br /> }es "tedUSOerator Conducting Inspection: <br /> TCC Ce r t if t a e# XX41411)1Expirati6n Date: f _f _ <br /> Sig naturePhone: 20 -649-8956 <br /> Y=Yes, N=1Jo, NA=Nut Applicable <br /> Item <br /> Monitoring Panel!Alarm History Y N NA <br /> �i Mariitonnrd syslemis powered on an m proper operating made. %� <br /> oil niliwing system is not currently showing any alarms or warnings. <br /> Alai in hisiory report1log or► e previous Month Is avai a e,an as een reviewed <br /> by Wie Designated LIST Operator_(Attach a copy of the alarm history repoiMog if available)_ ✓ <br /> 4 ac t it arm for f o previous month asbeet)responded to appropriate y. <br /> 5 Sensors oca a in tank-top containment sumps have ria alarmed to the past month. <br /> T a ist a Lank-top sumps w ere alarms occuffed in the past month: <br /> Now: Sumps wiwre an alarrrr has OCC6rrred in the past month most be inspected unless a qualified serviCe <br /> lechriiviura responded to, and properly addressed, the cause of the alarm. Attach documentation verifying <br /> apprrrprinle service to this report. If sump inspection is required,record results in ilern 6, below. <br /> UST System Inspection <br /> n -top containment sumps are ree ot water,debris,and hazardous su stance. <br /> Sensors are located properly. Note:Visual inspection of sumps are only required <br /> i n si.cps wr uftr an alarrn has occurr ad in the p ist month for which there is no service record <br /> umpLocation: ump ocatton: <br /> ,urn Location- atton: <br /> urnp Location: atton: <br /> pr containment structures are r e o wateJnl,�EH, us substance. <br /> an - antents: ITank 3-Contents: <br /> Tank 2- Contents: an 4-Contents: <br /> n er- rspenser containment areas are ree ot water, debris. and hazardous su stance. ensors <br /> are located property <br /> Dispenser ✓ ]Dispenser ✓ <br /> Dispenser 314 IDlspenser 11112 <br /> +sperp } er <br /> -]Dispenser 13114 .� <br /> i5 amiciDispenser 15/16 <br /> Paperwork Inspection Y N NA <br /> onitoring system certf tcatron as een compete wit to past Mori s. <br /> Seco_ a containment tests have been completed within requi red timeframe. <br /> spill containment structure uc et testing was completed within past year. <br /> an tag tress testtn was completed within required timeframes, <br /> me tick ilness testing was comp ete wit in require time rame <br /> er require esting main enance was comp e e wi in require ime rame. is maint. items below). <br /> est maintenance: <br /> Testlim—alritenance: <br /> es n>,arntenance: <br /> Facilit Em to ee TrainingY N NA <br /> �7aci ity ernp ayees have receive k e require on-the-job training in the past year. <br /> Maty employees hired within t e-past 30 days have received tiie require <br /> an-lite-ob training. <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. i'of 2 <br />