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Shell Food Mart, 2320 N. EI Dorado, Stockton_ , CA 95204 <br />Monthly Visual Inspection Check list <br />erh Name <br />_. Easels dress: 2.3 ,u -r <br />Deaf UST orstar Conductin t?ae ins ection: JK' . ' 77 • L <br />Intamational Code Co i1 Certify 'on #: 1 '>., ,4 �i / te,rExpiration Date: 12, t 1 /V <br />Si natttre; Phone: 2:.s X5`7 %i'C!' <br />x YYes. N - No. NANot ,a <br />Item <br />MONITORING PANEL / ALARM HISTORY Y I N NA <br />I <br />Monitoring system is powered on and inproper a fist mode:IVY I <br />2 <br />Monitoring system is not currently showing any alarnis or warnin s: IVI I <br />3 <br />Alarm history reporUlog for the previous month is available, and has been reviewed by the <br />ted USTOerator. Attach aao o the alarm histo re rdlo to this orm i available <br />4 <br />Fath alarm far th—."previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5' <br />list all tank -top sumps where alarms occurred in the past month: <br />Eater Sump; where an alarm has occurred in the past month must be inspected unless a. qualified service technician responded to, and <br />properly addrwed the cause of thr alarm. Attach documentation verifying appropriate service to this report. <br />ffsump int ion is reemimd. record results in item d below. <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps arc free of water, debris, and hazardous substance. Sensors are located property. <br />ole: Visual ins . o sa is onlyi uUcd in sm when an alarm has second in the t month which L=!" no service record <br />Y N y I N <br />Sum Lavation: / Sump Location: <br />Sump Location; sJ! Sump Location: <br />Sump Location: fse Sump Location: <br />Spill containment structures are free of water, debris, and hazardous substance. <br />7 <br />Y N NA Y JIN I NA <br />Tank 1 — Conlenu., a t Tank 3 —Consents: > zf <br />Tank 2 — Contents: < -- 1 Z1 I I Tank 4 — Comemts: <br />8 <br />Under dis er containment areas arc lice of water, debris, and hazardous substance. Sensors are located property. <br />Y I N I NA I I Y I N N <br />Dispenser I / 2 D' ensu 9110 <br />Dis eraser 3 i 4 . Dispenser 1I / 12 <br />Dispenser 516 Dis eraser 13114 <br />1}iss enser y 1 N D=r 15 / 16 v' <br />PAPERWORK INSPECTION Y NNA I DATE DONE <br />9 <br />Monitoring system certification has been completed within past 12 months. 1 2 7 2 i ti <br />to <br />Secondary containment tats have been com leted within the required timet'rarne. <br />11 <br />Spill containment atructuro(bucket) testing was completed within the past year. <br />12 <br />Tank tightness testing was completed within required timeframe. <br />13 <br />Line tightness testing was com letcd within required timeframa. <br />14 <br />Other required testis maintenance was completed within required timeframe. Lice tesdrnauujroanre draws below <br />TestlMnintenartve. <br />Tesilhlaintenance: <br />TestlMaintenance: <br />FACILITY EMPLOYEE TRAINING Y N I NA <br />t S <br />A!1 £stili em in ees have received the required on-the-job ttainin within the pariyear, 1/1 <br />16 1 <br />All facili tm to ees hired within the Mt 30 days have received the r uiic i on-the'ob training t,,r <br />Now Any answer of X14" should be explained In the comment section on the following page, and will reyttltrtt <br />follow-up action. <br />tI' <br />December 2014 D.O. report <br />Page 5 of 6 Photo taken on February 11, 2015 <br />