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2015-02-23 10.29 Safeway 1769 2094615559 >> P 2/10 <br /> Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Faplity Nama'SefeWay Facility Address: 2608 Country Club Blvd. Stockton,CA 95204- <br /> personConductinglnspasion:ftyanCasey Phone: 408}971-2445 Date:S/iy/12 <br /> Signature: <br /> Icc cerr8057554-UC i D31e:0 5/12 <br /> tnatmedons <br /> 1.The monthly UST system U,3pectian must be conducted by a Designated UST Operator who possesses s current"C4lifomla UST.S tem <br /> Operator'exam issued by die Intemallwal Code Council(ICC). <br /> 2.The Designated UST(*Valor must alert the UST Owner or Operator of any condition discovered during the monthly <br /> visual insp¢cU that <br /> may ragVire follow-Up action. <br /> 3.A copy of this monthly inspection repon most be provided to me UST Owner or Operator. <br /> 4.The UST Owner or Operator must maintain a copy of each monthly inspection report and all attachments for the most recent 12 mo the. <br /> The records shall be maintained onsite w,if approved by the local agency,offsite at a readily available location. <br /> Nofa:A=WW IlernS and SyS(am Items with"Y^dor yes,•N"for No and NA for Not Applicable.Any answer of"N'shoidd be explained <br /> in this commont searon and will require corlecove action from the UST ownerloperelor, <br /> Item Monitoring panel I Alarm History Y I N I NA <br /> 1 Is the monitoring system powered on and in proper operating made? Y <br /> 2 Is the monitoring system not cvmentiy showing any leak alarms or warninga? Y <br /> 3 IS the Alarm History re.porth0g for the pWidUS month available,and has it been reviewed by the Designated Y <br /> UST Operator? (Attach a copy¢f the alarm history rsporNog to this f iWacil"form if available.) <br /> 4 Has each alarm for the previous month been responded to appropdalely? NA <br /> UST System Inspection Y I N) NA <br /> 5 Are tank"top containment sumps free of water,debris,and ha2aedous substance?Ate sensors belted properly? <br /> Wre:Urha OrSm,00 to p4"S-Y13d)toa 0.SUMPSwh¢rb anspan has bommdin the pall month meat beinspected if.quardedserwtn 1whint,an <br /> h03 nor reapnMed M,endpmPeny addressed the 00430 Of dM orwm,Oac¢mbnfation v fiiirnp appmpdalir S¢Nka ahbdd tie adardod to this rap" <br /> Sump Location: Bump Location; <br /> Sump Location: Sung Location; <br /> Sump Location: Sump Location: <br /> 6 Are spill bucket.(containment S&Wurrss)free of water,derais,and hazardous substance? <br /> Tank 01RegoY I Tank <br /> TaNc 02•Plus Y Tank <br /> Tank 03-Prem Y I Tank <br /> 7 Are under-dispenser containment areas hoe of water,debris,and hazardous substance?Ara sensors located properly? <br /> Dispenser 01-02 Y Dispenser Dg-1D Y <br /> Dispenser 03.04 Y Dispenser 11-12 Y <br /> Dispenser 05-05 V Dispenser 19-14 y <br /> Dispenser D7-08 Y Dispenser 15.16 Y <br /> Paperwork inspection Y I N / NA bale Done <br /> 8 hWnitoring System Ce-rtitcation wait completed within the past 12 months? Y 1126W]12 <br /> g Una Leak Doteclors ware tastad/certiped within the past 12 months? Y 1/26112 <br /> 10 Spill containment structure(buckets)testing complawd within the past 12 months? Y 1/6/12 <br /> t1 Sacolslaly containment tests completed within the required time frame? Y 5/ 3111 <br /> 12 Other required testlnglmain[enanr'4 was completed within required time name? (list fastWumfanance litems below) <br /> Describe Test/Maintenance:Air Quality Y 1 2 112 <br /> Desoibi Tesumaintenance: �/ 1 <br /> Facility Employee Training Y I N I NA <br /> 13 Have all fadlliy employees receJved the required on-the-job veining within the past yeah Y <br /> 14 Have all facility crbployers hired within the past 30 days received the required on-the-job training? I NA <br />