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11 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facili Name:Date: <br />Inc- <br />Facility Address: <br />Cit <br />LP 2-1 <br />Zi Code: 95240 <br />Desi nated T erator Conducting the Inspection:Kell i <br />Kis i a <br />International Code Council Certification #5 2 4 9 0 2 7 — U C <br />Ex iration Date: 12 / 2 8 / <br />Si nature: <br />Phone: (209 368-0603 <br />/ Y = Yes N = No NA = Not Applicab <br />Item MONITORING PANEL / ALARM HISTORYN NA <br />Y <br />I Monitoring system is powered on and in proper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. ✓ <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy of the alarm history report'llog to thisform if available. <br />4 Each alarm for the previous month has been responded to appropriately. <br />5 Sensors located in tank -top containment sumps have not alarmed in thepast month. <br />5a _ List all tank -top sumps where alarms occurred in the past month: <br />Mole: 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 verging appropriate service to this report. <br />Ifsump inspection is re uired, record results in item 6, below. <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 o sum s is only re uired in sumps where an alarm has occurred in the past month or which there is no service record. <br />Y I N 0 1 N <br />Y <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Second2a containment tests have been completed within the required timeframe. <br />11 Sill containment structure bucket testing was completed within the past year, <br />12 Tank tightness testinR was com leted within required timeframe. <br />13 Line ti htness testingwas completed within required timeframe. <br />14 Other re uired testin /maintenance was com leted within required timeframe. (L <br />'11 k 01 SDA- <br />test/maintenance items <br />Page 1 of 2 November 2004 <br />Sump Location: <br />ounip Location: <br />Sump Location: <br />Sump Location: <br />Sump Location: <br />7 <br />Sill containment structures are free of water, debris, and hazardous substance. <br />Y N NA <br />N <br />NA <br />Y <br />Tank 1 —Contents: <br />Tank 3 — Contents,- <br />ontents:Tank <br />Tank2 — Contents: <br />Tank 4 — Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located to erl . <br />Y N NA N NA <br />Y <br />Dis enser 1/ 2 <br />✓ Dispenser 9110 <br />Dispenser 3 / 4 <br />Dis enser 11 / 12 <br />Dispenser S / 6 <br />Dispenser 13 / 14 <br />Dis enser 7 / 8 <br />Dispenser 15 / 16 <br />PAPERWORK INSPECTION <br />N <br />NA <br />DATE DONE <br />Y <br />9 Monitoring system certification has been completed within past 12 months. <br />10 Second2a containment tests have been completed within the required timeframe. <br />11 Sill containment structure bucket testing was completed within the past year, <br />12 Tank tightness testinR was com leted within required timeframe. <br />13 Line ti htness testingwas completed within required timeframe. <br />14 Other re uired testin /maintenance was com leted within required timeframe. (L <br />'11 k 01 SDA- <br />test/maintenance items <br />Page 1 of 2 November 2004 <br />