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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY VISUAL INSPECTION CHECKLIST <br />Facility Name Quik Stop Market # Lu't� <br />VU Date January 3, 2017 <br />Facility Address 2285 E. Fremont Strt <br />City, State, zip Stockton, CA 95205 1 6 7017 <br />Designated Operator Harold Largo An <br />ICC Certification # 8293993 Expiration November 13, 2018 <br />Signature ,-j- r- `,t- �'-ENVIR0NME:NTAL HEALTH Phone (916) 373-1166 <br />Item <br />1 <br />MONITORING PANEL / ALARM HISTORY <br />- .tem o .. <br />Monitoring system is powered on and in proper operating mode. <br />Y <br />E <br />N <br />❑ <br />NA <br />❑ <br />2 <br />Monitoring system is NOT currently showing any alarms or warnings. <br />■ <br />❑ <br />❑ <br />3 <br />Alarm history report / log for the previous month is available, and has been reviewed by the Designated UST Operator. <br />■ <br />❑ <br />❑ <br />3a <br />4 <br />Is a copy of the alarm history report/ log to this form? <br />Each alarm for the previous month has been responded to appropriately. <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />Sensors located in tank -top containment sumps have NOT alarmed in the past month. <br />❑ <br />❑ <br />5a <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 />If sump ins ection is re uired, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6_ �,� n—H.-nts mp-s-F.,-f kaw,._ t,r,d,-..-s—.ha-z -o _r Sensors <br />,�.'_- <br />_ �., . , ,,.._ <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note. Visual inspection of sumps is only required in sumps where an alarm has occurred in the past month for which there is no service record. <br />Y N <br />Sump Location: ❑ ❑ <br />Sump Location: ❑ ❑ <br />Sump Location: ❑ ❑ <br />7 Spill Containment Structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Tank 1 - Gasoline 87 M ❑ ❑ <br />Tank 2 - Gasoline 91 ■ El❑ <br />8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA <br />Dispenser 112 ■ ❑ ❑ <br />Dispenser 3 / 4 ■ ❑ ❑ <br />02017 ;,,;♦;-„;M Pagel Checklist P1 <br />