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e <br /> 4& <br /> DesignatewndergroundStorage r <br /> Monthly Visual Inspection Checklist <br /> acili Name' Date: <br /> FacilityAddress: <br /> Ci Zi C e: <br /> / �7alleyUnderground Tank Monitoring <br /> Mailing and Remittance Address: Valley Underground Tank Monitoring <br /> P.O. Box 91 <br /> Stockton, CA 95201 <br /> Desi nated UST Operator Conducting the Ins ection: <br /> International Code Council Certifi tion x iration Date: <br /> Si nature: <br /> Phone: ( <br /> Y=Yes,N=No, NA=Not Applicable <br /> ItemMonitoring el/Alarm HistoryY 14 NA <br /> --f--go—nitoring system is powere on an in proper operating mode. <br /> Monitoring system is not currently showing any a arms or warnings. <br /> Alarm Fistory report/log ort the previous month is available anas een reviewe <br /> by the Designated UST Operator. (Attach a copy of the alarm history repor0og if available). <br /> ac a arm or t e previous rmont as een reap on e to appropriately. 4� <br /> Sensors located-in an -op containment sumps ave not a arme in the pas most . <br /> a List all tan -top sumps w ere a arms o-cc-u-r-r-ea int e past month:-- <br /> Mote:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service <br /> technician responded to, and properly addressed, the cause of the alarm. Attach documentation verifying <br /> appropriate service to this report. If sump inspection is required,record results in item 6,below. <br /> UST System Inspection <br /> an -top containment sumps are ree o water,debris, and hazar ous substance. <br /> Sensors are located properly. Note:Visual inspection of sumps are only required <br /> i n sumps where an alarm has occurred in the past month for which there is no service record <br /> unlp ocatian: ump ocation: <br /> ump ocation: ump ocation: <br /> ump ocation: ump ocation: <br /> pr containment structures are ree o water, aIns, azar ous su stance. <br /> an - ontents: an - ontents: <br /> rT—ank-TContents: 1 4-- ontents: <br /> n er-dispenser containment areas are tree ot water, ens, an azar ous substance. Sensors <br /> are located properly. <br /> ispenser ✓ ispenser <br /> is—pe nserD ispenser <br /> ispenser � ispenser <br /> ispenser 778 spenser <br /> PaperworkInspection Y N NA <br /> onitoring s stem certificalto-n-Na-s-Eeen—c6-nipleted within past 12mint s. <br /> 77 econ ary containment tests ave ed within re uire time rame. <br /> Spill containment structure uc et—testing was completed within past year. <br /> Tank tightness testing was comp ete wit in require time rames. <br /> TT Line tightness testin was can uFre-d timeframe. <br /> Other require es ing main enance was comp e e With-in-required lime rame. (List maint. items below). <br /> es maintenance: <br /> es maintenance: <br /> Test/maintenance: <br /> Facility to ee Training Y N NA <br /> aci it emp o ees ave receive t e require on-the-job training int the past year. <br /> aci ity employees hired wit in t e past 30 days have received the require <br /> ]on-the-job training. <br /> Note: Any answer of"N"should be explained in the comment section on the following e, <br /> and will require follow-up action. <br /> Pg. 1 of 2 <br />