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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name:Safeway Facility Address: 2808 Country Club Blvd. Stockton, CA 95204- <br /> Person Conducting Inspection:Ryan Casey Phone:(408)971-2445 Date:5/14/12 <br /> i�;�.! <br /> Signature: CC Cert:8057554-UC Exp Date:9/15112 <br /> Instructions <br /> 1.The monthly UST system inspection must be conducted by a Designated UST Operator who possesses a current"California UST System <br /> Operator"exam issued by the International Code Council(ICC). <br /> 2.The Designated UST Operator must alert the UST Owner or Operator of any condition discovered during the monthly visual inspection that <br /> may require follow-up actions. <br /> 3.A copy of this monthly inspection report must be provided to the 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 months. <br /> The records shall be maintained on-site or,if approved by the local agency,off-site at a readily available location. <br /> Note:Answer items and system items with"Y"for Yes, "N"for No and NA for Not Applicable.Any answer of"N"should be explained <br /> in the comment section and will require corrective action from the UST owner/operator. <br /> Item Monitoring Panel/Alarm History v / N / NA <br /> 1 1 Is the monitoring system powered on and in proper operating mode? Y <br /> 2 Is the monitoring system not currently showing any leak alarms or warnings? Y <br /> 3 Is the Alarm History reportAog for the previous month available,and has it been reviewed by the Designated Y <br /> UST Operator? (Attach a copy of the alarm history roport4og to this inspection form if available.) <br /> 4 Has each alarm for the previous month been responded to appropriately? NA <br /> UST System Inspection Y1 N / NA <br /> 5 Are tank-top containment sumps free of water,debris.and hazardous substance?Are sensors located properly? <br /> Note:If the answer to#4 was"Y",skip to#6.Sumps where an alarm has occured in the past month must be inspected if a qualified service technician <br /> has not responded to,and property addressed the cause of the alarm.Documentation verifying appropriate service should be attached to this report. <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> 6 Are spill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Tank 01 -Rego Y Tank <br /> Tank 02-Plus Y Tank <br /> Tank 03-Prem Y Tank <br /> 7 Are urMer-dispenser containment areas free of water,debris,and hazardous substance?Are sensors located properly? <br /> Dispenser 01-02 Y Dispenser 0310 Y <br /> Dispenser 03-04 Y Dispenser 11-12 Y <br /> Dispenser 05-06 Y Dispenser 13-14 Y <br /> Dispenser 07-08 Y Dispenser 15-16 Y <br /> Paperwork Inspection Y / N / NA Date Done <br /> 8 Monitoring System Certification was completed within the past 12 months? Y 1/26/12 <br /> 9 Line Leak Detectors were tested/certified within the past 12 months? Y 1/26/12 <br /> 10 Spill containment structure(buckets)testing completed within the past 12 months? Y 1/26/12 <br /> 11 Secondary containment tests completed within the required time frame? Y 5/13/11 <br /> 12 Other required testing/maintenance was completed within required time frame? (List test/Mamtenance items below.) <br /> Describe Test/Maintenance:Air Quality Y 2/7/12 <br /> Describe Test/Maintenance: <br /> Facility Employee Training Y / N / NA <br /> 13 Have all facility employees received the required on-the-job training within the past year. Y <br /> 14 Have all facility employees hired within the past 30 days received the required on-the-job training? NA <br />