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1 0 1 <br />1 W01 W01 MTV to] loked URN V; I WA 11:61 M BE" V <br />z. <br />Facility Name: Circle K Site #5446 <br />Inspection Date: April 30, 2012 <br />Facility Address: 1403 Country Club Blvd. <br />11 City: Stockton <br />Name of Designated UST Operator Conducting Inspection: Atila Gil Fernandes <br />International Code Council Certification No.: 4341059940 <br />Date: 12/28/2012 <br />Signature: <br />Phone: 774-5066 ext. <br />UNI -057 -113 www.unidocs.org 9/26 5 <br />Is the monitoring system powered on and in proper operating mode? <br />'"D <br />Is the monitoring system not c!!rrently jhq larms? <br />"M <br />___g <br />Is the Alarm History Report/log for the previous month available, and has it been reviewed by the <br />Designated UST Operator? Atlach a co q the alarm hisloryre to this inspectionform.) <br />i <br />- - - - ------- <br />UST SYSTEM INSPECTION <br />Are tank -top containment sumps free of water, debris, and hazardous substanc—le.9 Note: ffthe annver to Item 4 was Yes." skip <br />to Item 6. Sum Mere an alarm has occurred in st month must be s cted i a ua lited service technician has not responded to, and <br />Kim- Imm, <br />)cation: <br />Sump Location: <br />In. W-311 11111"Mr. 11M I <br />Yes No N/A <br />Tank I ID - 87 Tank 4 ID - waste oil <br />Tank 2 ID - 91 N FMIM t� <br />Tank 3 ID - DIESEL W12ta <br />ier - 3/4 <br />r - 5/6 <br />Dispenser - 15/16 <br />MNI 1011 a IRMMS #NUMMA IMI Gqrl <br />Dispenser - 112 <br />BIFA <br />0 0, f0141 1 tq4 <br />4311610171141= I a I <br />in? �Wla <br />fiffletm <br />UNI -057 -113 www.unidocs.org 9/26 5 <br />