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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY Vk&W kE A6MWIAN4ECKLIST <br />Facility Name Quik Stop Market #138 ' a `-° 4*° A V V— V Date September 9, 2016 <br />Facility Address 1153 Lincoln Blvd. OCT 2 0 2017 <br />City, State, Zip Tracy, CA 95376 <br />Designated Operator Harold Largo <br />ICC Certification # 8293993 ENVIRONMENTAL HEALTH Expiration December 18, 2016 <br />Signature �, !,,,./�G� ' DEPARTMENT Phone (916) 373-1166 <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 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 />Y <br />N <br />Sump Location: ❑ ❑ Sump Location: <br />❑ <br />❑ <br />Sump Location: ❑ ❑ Sump Location: <br />❑ <br />❑ <br />Sum Location: ❑ ❑ Sum Location: �® <br />._.,.__A y.._., v . _.-- U . _ -_ _ w .. ___ rn,.. _. <br />❑ <br />11 _ <br />7 Spill Containment Structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Y <br />N NA <br />Tank 1 - 87 0 ❑ ❑ Tank 3 - 91 <br />N <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 0 ❑ ❑ <br />Dispenser 3/4 ■ ❑ ❑ <br />FACILITY EMPLOYEE TRAINING Y N I NA <br />15 All facility employees have received the required on-the-job training within the past year. ❑ ❑ <br />16 All facility employees hired within the past 30 days have received the required on-the-job training. ❑ ❑ <br />0zou Vi-_ - Page 1 Checklist P1 <br />