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P RECEIVED <br /> Designated Underground Storage Tank (UST) Operator JUN 13 Z017 <br /> Monthly Visual Inspection Checklist <br /> Facility Name: French Camp Date: • 0 <br /> FacilityAddress: 10842 S.Harlan Rd. P D L.�E STA L H p`� <br /> City:French Cam Zin Code:95231 r: .a. NT <br /> Designated US ator Conducting the Inspection: Steven Richardson <br /> Internationa n ' ertification#: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 proper operating mode. XM , <br /> 2 _iZo—nitoring 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 co o the alarm histo re ort/lo to this orm i available. <br /> 4 Each alarm for the previous month has been responded to appropriately.,__ <br /> X <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> Sa - 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 /> I sum inspection is re uired record results in item 6,below. <br /> x <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual inspection of sums is on re uired in sum s where an alarm has occurred in the past month or which there is rto service record <br /> Y N Y N <br /> Sump Location: Sum Location: <br /> Sum Location: Sum Location: <br /> Sum Location: Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1—Contents.DFC X Tank 3—Contents: <br /> Tank 2—Contents: Tank 4—Contents: <br /> 8 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 1 a X Dispenser 5 X <br /> Dispenser 112 X Dispenser <br /> Dis enser 3/4 X Dispenser <br /> Dispenser 4a/5a X Di s enser <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> F12Monitorin s stem certification has been con leted within ast 12 months. X 10-30-14Seconds containment tests have been con leted within the re uired timeframe. X 12-17-14 <br /> S ill containment structure bucket testin was con leted within the ast ear. X 10-30 i�Tank tihtness testin was corn leted within re uired timeframe.Line tightness testing was completed within required timeframe. X <br /> 14 Other required testin maintenance was completed within required timeframe. (List test/maintenance items below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING 4 <br /> 4YN NA <br /> 15 All facilit em 10 ees have received the re uired on-the-'ob trainin within the ast ear. <br /> 16 All facility em to ees hired within the 2ast 30 days have received the required on-the-'ob training. X <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 />