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DesignatedRinderground <br /> Monthly Visual I oChecklist <br /> Facili Name: Date: <br /> Facili Address: <br /> Cl i Code: <br /> Valley er ro n Tank Monitoring <br /> ,=f:IZ <br /> Mailing and Remittance Address: Malley Underground Tank Monitoring <br /> P.O. Sox 91 <br /> Stockton, CA 95201 <br /> E!EE <br /> oe ouncil Certifi tion Expiration <br /> Si nature: r� Phone: ( e <br /> Y=Yes,N=No, PIA=Not Applicable <br /> Itemoniorin Panel/ lar HistoryY NA <br /> onitoringsystemispowere on and in operating <br /> -Monitoring system is not currently showing any alarms or warnings. <br /> arm Istory repo og fort e previous mont is avai a e,an as 6een reviewed <br /> by the Designated UST Operator. (Attach a copy of the alarm history report/log if available). Er` <br /> ac rm a aort e prevaous moot as een respon-ed to appropriate y. -� <br /> ensors oca in tan -top containment sumps ave no a arme In e pas mont . <br /> a <br /> a List all tan -top sumps where a arms occurre int e past mont : <br /> f ✓`'i11 <br /> Note: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 /> T System Inspection <br /> an -top containment sumps are free of water,debris, and hazardous 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 /> ump ocatlon: 61, Vn -apz <br /> ation: <br /> ump Location: atm in: <br /> ump ocatlon: atlon: <br /> pi containment structures are free 3wa , us su b sta ce. <br /> Y NA <br /> Tank - ontents: an - ontents: <br /> Tank - ontents: an - ontents: <br /> n er-dispenser containment areas are ree o water, a ns, an azar ous su stance. ensors <br /> are located properly. <br /> Ispenser Ispenser <br /> Ispenser 4 Ispenser <br /> Ispenser 7 Ispenser 4 <br /> Ispenser Ispenser <br /> Paperwork Inspection Y N NA <br /> onitorin system cert) (cation has been compete wit In past Mont s. <br /> econ ary containment tests ave een camp ete with Inrequire time ram . <br /> pi containment structure(bucket)testing was completed within past year. f' <br /> an tig tress testing was camp ete wit in required timeframes. <br /> ire tig tress testing was completed within r5quired timeframe. <br /> 4 er requiretesting/maintenance was completedwi In require line rame. (List maim. items below). <br /> es maintenance: <br /> es maintenance: <br /> Testlmaintenance: <br /> cilit Employee Training Y N N <br /> ace it emp oyees ave receive the require on-t a-to training int the past year. <br /> as Ity employees ire within the past ays ave receive t e requireF <br /> on-the-job training. <br /> Note: Any answer "N"-should-be explained in the comment section on the following page, <br /> and will require follow-up action. <br /> Pg. 1 of 2 <br />