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E <br />E <br />DESIGNATED UNDERGROUND s OPERATOR <br />MONTHLY VISUAL <br />Facility Name <br />Quik Stop Market # 76 <br />Date April 6, 2015 <br />Facility Address <br />1030 S. Olive Avenue <br />Monitoring system is NOT currently showing any alarms or warnings. <br />City, State, zip <br />Stockton, CA 95215 <br />❑ .' <br />Designated Operator <br />Harold Largo <br />❑ <br />ICC Certification # <br />8293993 <br />Expiration December 18, 2016 <br />Signature <br />f� r.(� ' <br />Phone (916) 373-1166 <br />Item MONITORING PANEL / ALARM HISTORY <br />1 Monitoring system is powered on and in proper operating mode. <br />Y <br />N <br />❑ <br />NA <br />❑ <br />2 <br />Monitoring system is NOT currently showing any alarms or warnings. <br />0 <br />❑ <br />❑ .' <br />3 <br />Alarm history report / log for the previous month is available, and has been reviewed by the Designated UST Operator. <br />❑ <br />❑ <br />❑ <br />3a <br />/s a copy of the alarm history report/log to this form? <br />N <br />❑ <br />❑ <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />❑ <br />❑ <br />■ t <br />5 <br />Sensors located in tank -top containment sumps have NOT alarmed in the past month. <br />0 <br />❑ <br />❑ <br />5a <br />List all tank -top sumps where alarms occurred in the past month: <br />Other required testing/ maintenance was completed within the required timeframe. (List items below) <br />Testl Maintenance Air Quality Test <br />Testl Maintenance <br />05/13/14 <br />E <br />❑ <br />❑ <br />❑ <br />❑ <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a quaffied service technician responded to ,and <br />properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />f€sum ins coon is required, record results in item 8, below. <br />UST _SYSTEM INSPECTION <br />6 Tank tap containment sumpsare free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection of sumps is only required in sumps where an alarm has occurred in the past month for which there is no service record. <br />Y N <br />Sump Location: ❑ ❑ <br />Sump Location: ❑ ❑ <br />Sump Location:.._ �__._......... .. _. _...... _El .®..., <br />7 Spill Containment Structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Tank 1 - Gasoline 87 ■ ❑ ❑ <br />Tank 2 - Gasoline 91 ❑ ❑ <br />8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA <br />Dispenser 112 E ❑ ❑ <br />Dispenser 314 ■ ❑ ❑ <br />9 <br />,.., .,. PAPERWORK INSPECTION <br />Monitoring system certification has been completed within the past 12 months. <br />Date <br />07/02!14 <br />Y <br />■ <br />N <br />❑ <br />NA <br />El <br />10 <br />Secondary containment tests have been completed within the required timeframe. <br />10/23/13 <br />0 <br />1 ❑ <br />❑ <br />11 <br />Spill containment structure (bucket) testing was completed within the past year. <br />07/02/14 <br />0❑ <br />❑ <br />12 <br />Tank tightness testing was completed within the required timeframe. <br />❑ <br />❑ <br />■ <br />13 <br />Line tightness testing was completed within the required timeframe. <br />❑ <br />❑ <br />■ <br />14 <br />Other required testing/ maintenance was completed within the required timeframe. (List items below) <br />Testl Maintenance Air Quality Test <br />Testl Maintenance <br />05/13/14 <br />E <br />❑ <br />❑ <br />❑ <br />❑ <br />© 2015 w'"' — Page 9 unecKOst vi <br />