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E.CEIVED <br /> Designated Underground Storage Tank (UST) p <br /> Monthly Visual Inspection Checklist U 2017 <br /> it Name:French C <br /> Facilam Date: j(- <br /> Facilit Address: 10842 S. Harlan Rd. <br /> Cit :French Cam Zi Code:95231 'g <br /> Designated UST rator Conductin the Ins ection: Steven Richardson <br /> International d u Cil Certification#:8218604 " <br /> Expiration Date: 8 / 29 /17 <br /> Signature: �, Phone: 916 825-7412 <br /> ItemMONITORING PANEL/ALARM HISTORY No NA=Not A lic <br /> Y N NAA <br /> 1 Monitorin s stem is owered on and in ro er o eratin mode. <br /> 2 Monitorin s stem is not currentl showin an alarms or warnin s. X <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the X <br /> Desi ated UST O erator. Attach a co o the alarm histo re I I l2g to this form if available.) <br /> 4 Each alarm for the revious month has been responded to appropriately. <br /> 5 Sensors located in tank-to containment sumps have not alarmed in the past month. X <br /> 5a X <br /> 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 ins ection is re uired,record results in item 6,below. <br /> UST SYSTEM <br /> 6 Tank-toINSPECTION <br /> p containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual ins ection o sum s is onl re uired in sum s where an alarm has occurred in the past month for which there is no service record. <br /> Y N Y N <br /> Sum Location: Sum Location: <br /> Sum Location: Sum Location: <br /> Sum Location: Sum Location: <br /> 7 S ill containment structures are free of water,debris,and hazardous substance. <br /> Tank 1—Contents: Y N NA Y N NADFC X Tank 3—Contents: <br /> Tank 2—Contents: Tank 4—Contents: <br /> 8 Under-dis enser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N <br /> Dis enser I a NA Y N NA <br /> X Dis enser 5 X <br /> Dis enser 1/2 X Dis enser <br /> Dis enser 3/4 X Dis enser <br /> Dis enser 4a/5a X Dis enser <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring s stem certification has been com leted within past 12 months. X <br /> 10 Secondary containment tests have been com leted within the re uired timeframe. X 10-30-15 <br /> 12-17-14 <br /> 11 S ill containment structure bucket testin was com leted within the,past year. X <br /> 12 Tank tightness testin was completed within required timeframe. 10-30-15 <br /> 13 Line ti tness testin was completed within required timeframe. X <br /> 14 Other re uired testin maintenance <br /> Twas com leted within required timeframe. (List test/maintenance items below.) <br /> est/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE <br /> 15 All facTRAINING y ?,N � NA <br /> ilit em to ees have received the re uired on-the-'ob trainin within the past year. X <br /> 16 All facilit em to ees hired within the ast 30 da shave received the re uired on-the-'ob trainin 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 />