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'JNAC�OUND STORAGE TANK Sy <br /> DESIGNATED UST OP <br /> ERATOR MONTI(LY INSPECTION <br /> REPORT <br /> � Facility Name; - <br /> �"" fa+trj----1 Inspection Date:; t3�Cl�/i <br /> FacilityAddress: <br /> 6931 Pacific Avenue City: Stockton, Calitorni 52.107 <br /> Name of Designated UST Operator Conducting Inspection: <br /> Kathy Kotulak <br /> International Code cil Ce <br /> rti4cation No.: 5240722-UG Expiration Datc: <br /> Signature: 7/27/2018! flll <br /> Phone: (925)413-7422 ext. <br /> Item. MONITORIING PANEL/ALARM HISTORY NIA a Not A ltcsble <br /> 1. Is the monito ' s or o eres No N/A <br /> tom owered on and in ro atin mode? <br /> 2. Is the monitorm s n1 not cumently showin py leak alarms? <br /> 3• Is the Alarm History Report/log for the previous month available,and has it been reviewed by tfie <br /> Desi ated UST 0 ratoz'1 Attach a copy <br /> o the alarm history report/logrepqq#og to this i ection . <br /> form � ❑ <br /> 4. Has each alarm fOrtlre mvious month been r` onded to ro riatel <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:Ythe answer to Bern 4 was~Yes,".skip <br /> to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has notresponded to,and <br /> ro <br /> ly addressed the twuse o the alarm.Dna�rthentatlo+t veri n ro state service should be attached to thisreport <br /> Yes No Yes No <br /> Sum Location: Sump Location: <br /> Sum Location. Sum Location: <br /> 6. Are ill buckets containment stru of water bris and hazardous substance? <br /> /A <br /> Tank 1 ID–Re No 8? Tank 4 ID– <br /> Yes. No N/A <br /> 77 <br /> -- Tank 2 ID–Premium 91 Tank 5 ID- ❑ <br /> Tank 3 ID–Diesel#209 1 1 1Tank 6 ID– <br /> 7. Are under-di er containment areas free of water debris and hazardous substance? <br /> Yes No N/A Yes- No N/A <br /> D' eraser•='1/2 Di enser– <br /> D' er–V4 -anD' eraser– <br /> D' er-5/6 ElDrs enser– <br /> D' eraser.-7/8 Di eraser– <br /> 8. beak detection is pro erl located within under=d' enser containment, <br /> Yes No N/A <br /> D' rases–1/2 No N/A Dis er– <br /> Yes <br /> Di erlset•–3/4 D' enser– <br /> L7' er–5/6 D' er Dispenser=7/8 ❑ D er– <br /> 'PAPERWORK INSPECTIONXes No /A Date Done <br /> 9. Monitorin S Cer#ificatioti was co . leted within the past 12 months? El I El <br /> 10. Line Leak D---ors were tested/certified within the vast 12 months? El 10 <br /> 11. S * bucket contain p— structure testing completed within the past 12 months? <br /> 12. Lino ti taws tcstihR CoTpletod within the required time frame? <br /> l'3. Sewn containment tests co the Ieted within ' ed time frame? <br /> I4. Enhanced Leak Detection co leted within the required time frame? <br /> ls• Otherrequiredres ' ntaititenar cc was completed within required time.fiame? ist testlmaintenance iteim below. <br /> I7escnba Test/Maintenanceawwawg.:CSU)Dail Test Report <br /> Describe1110 <br /> .Test/Maintenaace: I H <br /> lllmffiamslw� <br /> FACILITY EMPLOYEE TRAINING Yea lYo N/A <br /> F16. ve all facili to eea received the aired on-the-'ob withinthe ast!'lave all facili employees hired within the pw 30 days received the required on the-'ob . ,? <br /> Note: iXplaia any"No"answers in the``Comments"section on the followingpage.Those is <br /> the UST owner/operator. p g sues require co tive aetioit from <br /> UN-057-W www.unidocs org 9n6/os <br />