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Designated Underground Stori`ge Tanis (UST) Operator <br /> _ Monthly Visual Inspection Checklist <br /> li acili Narfie_ / , i Date: <br /> t'=aciiit Ad fess: 1' J <br /> Cit - ' Zip Code: <br /> Valley Undergroirrid Tank Monitoring <br /> Mailing and Remittance Address: Valley Underground Tank Monitoring <br /> P.O. Box 91 <br /> Stockton, CA 95201 <br /> Uc,si ndtred UST 012efatDr Conducting the inspection.- <br /> TCC <br /> ns ection:TCC Certifi/c 4 Expiration Date: <br /> Signature' Phone: 20 <br /> Y=YeL N=No, INA=Nut Applicable <br /> (tern _ <br /> Monitoring Panetl Alarm History Y N , NA <br /> onitonng <br /> —system is powered on and In proper operating mode. <br /> anrtofing systern is not current y s owing an a arms or warnings. <br /> arm hib tory_reportllog fort the previous mon!h is availabie,and has been reviewed <br /> by the Designated. UST Operator_ (Attach a copy of rhe alamr history reporoog if available)_ � <br /> 4ae <br /> �a arm ort the previous month has been respondeg lo appropriately. <br /> 5 Sensors located-in tan -top containment sumps have not alarmed in the past month. <br /> a List all tan -tap sumps where alarms occurred in the past mon J � <br /> NOW. SUMPS wfrere an atarrrr has occurred in the past month Must be inspected unless a qualified service <br /> tr diniciuir responded to; and properly addressed,the cause of the alarm. Attach documentation verifying <br /> applapria4a service to this report. if sump inspection is required,record results in item 6, below. <br /> UST S stem Ins ection <br /> n c-top containment sumps are free ot water,;;debris,and hazardous,su stamce. <br /> sensors are;located properly. Noie Visual inspection of sumps are only required <br /> i n sU. ps Whot,u an alarm has occuaW in Me past morith for which there is no service recon] <br /> ump ocation: <br /> Sumplocation: <br /> Surnp Location-' Sump acalion: <br /> _S__(_Tl Focation: um ocation: <br /> pr containment structures are ree o water, ens,an azar aus su stance. <br /> an - ontents: ijTajContents: <br /> Tank 2- Contents: r an 4-Contents: <br /> Under-dispenser containment areas are tree of water, errs,an hazardous su stance. ensors <br /> are located foperiy. <br /> Dispenser / ispenser 9/10 <br /> ispenser r' isp�nse <br /> Dispenser 5]' is eraser 4 r° <br /> Dispenser 11b Dispenser <br /> 15/16 <br /> Paperwork inspection Y N NA <br /> ondonng system cerci kation has been completed within past months. ` <br /> _RF'9econdarV containment tests have been completed within require time rame. <br /> pi containment structure uc et testing was completed within past year. <br /> Tank tightness testing was completed wit m required time fames. <br /> ia Line tightness testing was iin required timeframe. <br /> 14 Other require es in mem enance was completed wt in required timetrame. (List mainf. items below). <br /> e maintenance. <br /> est maintenance <br /> Te-s-Tniaintenance: <br /> !Facility Em to ee Training Y I N I NA <br /> _ 15 I Caei ity emp oyees have received the require on-the-job training int the past year. k <br /> {ac city employees nirea within itfie past ays ave received the fequire <br /> On-the-job gaining. <br /> Note: Any answer of "N" should be explained in the comment section on the folia tng age, <br /> and will require follow-up action. <br /> Pg. 1'pf 2 <br />