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IVED <br /> F <br /> � a <br /> Designated Underground Storage Tank (UST) Of er R° <br /> Monthly Visual Inspection Checklist JLJN 13 2017 <br /> Facility Name: French Camp Date: <br /> Facility Address: 10842 S.Harlan Rd. -, <br /> City: French Cam Zi Code:95231 <br /> Designated UST Operator erator Conductin the Inspection: Steven Richardson <br /> International Code Council Certification#:8218604 Ex iration Date: 8 / 29 /17 <br /> Signature: Phone: 916 825-7412 <br /> Y=Yes N=No NA=Not Applicable <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in ro er o eratin mode. X <br /> 2 Monitoring system is not currently showing any alarms or warnings. X <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the X <br /> Designated UST Operator. Attach a copy of the alarm history re ort/lo i to this form if available.) <br /> 4 Each alarm for the previous month has been responded to appropriately. X <br /> 5 Sensors located in tank-to containment sumps have not alarmed in the past month. X <br /> r5a _ List all tank-top sumps where alarms occurred in the past month: <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br /> properly addressed the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> If sump ins ection is required record results in item 6,below. <br /> UST SYSTEM INSPECTION <br /> F" �6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual inspection of sumps is onl re uired in sumps where an alarm has occurred in the past month for which there is no service record. <br /> Y N Y N <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> NDiVenser <br /> Location: Sum Location: <br /> ontainment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> —Contents:DFC X Tank 3—Contents: <br /> —Contents: Tank 4—Contents: <br /> Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N NA Y N NA <br /> Dispenser la X Dis enser 5 X <br /> 1/2 X Dis enser <br /> Dispenser 3/4 X Dispenser <br /> Dis enser 4a/5a IX Dis enser <br /> EM <br /> PAPERWORK INSPECTION Y N NA " DATE DONE <br /> 9 Monitorings stem certification has been completed within past 12 months. X 10-30-14 <br /> 10 Second2ry containment tests have been completed within the required timeframe. X 12-17-14 <br /> 11 Spill containment structure bucket testing was completed within the pastear. X 10-30- " <br /> 12 Tank tightness testingwas completed within required timeframe. X <br /> 13 Line tightness testing was completed within required timeframe. X <br /> 14 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> NAFACILITY EMPLOYEE TRAINING Y <br /> 15 All facilityemployees have received the required on-thejob training within the past year. <br /> 16 All faciliem to ees hired within the ast 30 days have received the required on-thejob tr <br /> ainin <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Page 1 of 2 November 2004 <br />