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0 <br />01/24/2008 20:49 FAX <br />i <br />16 005 <br />Designated Underground Storage Tank (UST) Operator <br />I onthl r Visual Inspection Checklist <br />Facility Name: lupon Shell <br />Facifi Address: 341 W Main <br />Citv: Ripon <br />Desi ed UST QpE2 or Conducting the I <br />Internationalode Cou it Certification #: <br />Si e: 44o rY1 fah _ <br />LW <br />on and in <br />I Uate: 10- _ 5c <br />zip CO& _ <br />< tion: Lori Freshour -" <br />220353 - UC Ea iration Date: p -p <br />Phone: �b -r <br />3 1 :Alarm history report., log fix the previ mrnrth is available, and has been reviewed by the Designated LIST Operator. <br />l lttach a copy oJ'the alarm h, log- report / is ti to ryas orm a anaalable) <br />4 Cach alarm for the EUvioux month has been r x ponded to nate! , $ 2 l -1 d <br />5 S.aorx located in the taatop cont tinntont slum have not alarttk d in dw past month <br />Sa List all tank -top sumps whets alarms occurre.! in the past month: <br />,Vote: Sumps wheat an alarm has occurred an r„*'past month must be inspected unle.rs a gr{ahfred service techructon_ _ rs.Yponded to. and N <br />properly addressed, the rouse of rbc alarm, A n •7ch documentation vemfying appropriate service to this report <br />Ifs7imp ins action is required. record iv,*4Its r. item 6, below. <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of wa er, debris, and hazardous substance. Sensors are property located <br />Nate: Visual Myoujon of sumps is only in sir cps where an alarm has omwad in the past monlh for which there is no service rewd <br />_Samp Location: <br />Sump Location <br />SEill containment stnx <br />Tank 1- Contents t A <br />Tank 2 - Contents- <br />UDC <br />ontentsUDC areas are free of <br />are free of waler, <br />and h;_ardour <br />P_1i!1___A Sump Locaiorr <br />substance. <br />I Tank 4 -- Contel <br />are property located <br />Y N I NA <br />Div enser 112 Dis nser 9 / 10 <br />Y N FNA <br />N <br />_ <br />Dispenser314 _ Diskensiv 11 / 12 <br />Di nser 516 Dispenser 12/ 13 <br />DIVer"r 718 Di enser 14/ 15 <br />PAPERWORK INSPECTION Y N NA <br />DATE DONE <br />9 Monitoring system certification has been con4Aeted within the 12 months, <br />b -� <br />-past <br />10 Secondary Containment tests have been C(I-1pleted within the required timeframe, <br />11 Spill containmett stnxdure(bucket) testing ri as iletedwithin the past year, er -- o-7 <br />12 L Tank tihMaw testing was completed within red timeframe. <br />13 Line ti htness testing was OuVeted with mquired timeframe. > 4 <br />14 Other required testrig maintenance was completed within re quired timeframe. List test/maintenance items below <br />Test/ Maintenance: _ L L Tp <br />Test/ Maintenance: <br />Y N I NA <br />Test/ Maintenances <br />_ <br />FACILITY EMPLOYEE TRAINING <br />15 All facility employees have received the recpli'ed on-th 'ob training within the past year. <br />16 All facility employees hired within the past 3r) day have received the required on-the-job training <br />-vK+• rYy .0 v .1ow"Ow W WAIJt41110U 141 tilt G JWnMMt Ummon On Tne Tonowing page, ana wm require Tonow-up anion. <br />Comments: U n C!1- -4, nR �l - f <br />-�—t - <br />Follow-up action required: <br />Dealer 16Manager Signature, <br />