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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY VISUAL INSPECTION CHECKLIST <br />Facility Name Quik Stop Market Date <br />August 9, 2017 <br />Facility Address 1153 Lincoln BlvdritECEIVED <br />City, State, zip Tracy, CA 95376 <br />Designated Operator Carpenter, Curtis OCT 2 0 2017 <br />ICC Certification # 8167865 -UC Expiration <br />February 5, <br />2019 <br />Signature '/ �G�'_._.— ENVIRONMENTAL HEALTH Phone <br />(916) 373-1166 <br />Item MONITORING PANEL / ALARM HISTORY <br />Y <br />N <br />NA <br />1 Monitoring system is powered on and in proper operating mode. <br />0 <br />❑ <br />Cl <br />2 Monitoring system is NOT currently showing any alarms or warnings. <br />■ <br />❑ <br />❑ <br />3 Alarm history report / log for the previous month is available, and has been reviewed by the Designated UST Operator. 0 <br />❑ <br />❑ <br />3a Is a copy of the alarm history report /log to this form? <br />E <br />❑ <br />❑ <br />4 Each alarm for the previous month has been responded to appropriately. <br />0 <br />❑ <br />❑ <br />5 Sensors located in tank -top containment sumps have NOT alarmed in the past month. <br />❑ <br />0 <br />❑ <br />5a List all tank -top sumps where alarms occurred in the past month: <br />All sensors <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 sume ins ection is re uired record results in item 6 below. <br />UST SYSTEM INSPECTION <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 Y <br />N <br />Sump Location: ❑ ❑ Sump Location: <br />❑ <br />❑ <br />Sump Location: ❑ ❑ Sump Location: <br />❑ <br />❑ <br />Sump Location ❑ I] Sump Location: <br />_ x....v. _._M.. _.. <br />❑ <br />❑ <br />7 Spill Containment Structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Y <br />I N INA <br />Tank 1 - 87 0 ❑ ❑ Tank 3 91 <br />❑ <br />❑ <br />Tank 2 - 89 N ❑ ❑ <br />8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA <br />Dispenser 1/ 2 E ❑ ❑ <br />Dispenser 3/4 0 ❑ ❑ <br />0 2017 x �,..�.K,-__._ Page 1 Checklist P1 <br />