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Site ID: 1604-1 <br /> Afforda-Te$t Designated Operator <br /> 4162 nd Street g P <br /> Galt, Ca 95632 Monthly Inspection Checklist <br /> 209-744-0112 Fax 209-744-0116 <br /> Site: Cherokee Lanes Service Station Date: 9/10/10 <br /> 900 S. Cherokee Lane <br /> Lodi, CA 95240 <br /> ❑ Lyle D.Nimmo ® Zane A.Nimmo ❑ David A.Winkler ❑Felix G.Ramirez <br /> #5249115 #5263322 #5263373 #5273934 <br /> Signature: <br /> Y=yes N=no,NA=not applicable <br /> MONITORING PANEL /ALARM HISTORY Y N NA <br /> Monitoring system is powered on and in proper operating mode. X <br /> Monitoring system is not currently showing any alarms or warnings. X <br /> Alarm history report/log for the previous month is available,and has been reviewed by the Designated UST X <br /> Operator. Attach a copy of the alarm history report/log to thisform if available.) <br /> Each alarm for the previous month has been responded to appropriately X <br /> Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> List all tank-top sumps where alarms occurred in the past month: <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and properly <br /> addressed,the cause of the alarm. Attach documentation verifying appropriate service to this report.If sump inspection is required,record results <br /> in item 6,below. <br /> UST SYSTEM INSPECTION <br /> Y I N I NA I I Y I N I NA <br /> Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual inspection of sumps is only required in sum s where an alarm has occurred in the past month or which there is no service record. <br /> Sump Location: 87 X Sump Location: X <br /> Sump Location:91 X Sump Location: <br /> Sump Location: DIESEL X Sump Location: <br /> Spill containment structures are free of water,debris,&hazardous substance. <br /> Tank 1 -Regular X Tank 4-Diesel X <br /> Tank 2—Plus X Tank 5- <br /> Tank 3-Premium X Tank 6- <br /> Under-dispenser containment free of water,debris,&hazardous substance. Sensors located properly. <br /> Dispenser 1/2 X Dispenser 19/20 X <br /> Dispenser 3/4 X Dispenser 21 X <br /> Dispenser 5/6 X Dispenser 22/21 X <br /> Dispenser 7/8 X Dispenser 23/22 X <br /> Dispenser 9/10 X Dispenser 24/23 X <br /> Dispenser 11/12 X Dispenser 25/24 X <br /> Dispenser 13/14 X Dispenser 26/25 X <br /> Dispenser 15/16 X Dispenser 27/26 Satellite X <br /> Dispenser 17/18 X Dispenser 27 X <br />