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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY VISUAL WSMG110"HECKLIST <br />Facility Name Quik Stop Market #1 In Low % ,d "1 V 1. ✓ Date November 8, 2016 <br />Facility Address 1153 Lincoln Blvd. <br />City, State, Zip Tracy, CA 95376 O C T 2 0 2017 <br />Designated Operator Harold Largo <br />ICC Certification # 8293993 ENVIRONMENTAL HEALTH Expiration December 18, 2016 <br />Signature ..,�r p7 ��`' 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 />Sump Location: ❑ ❑ Sump Location: <br />Sump Location: ❑ ❑ Sump Location: <br />Sump Location - _® . _ 0 _.....(] Sump Location <br />7 Spill Containment Structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Tank 1 - 87 0 ❑ ❑ Tank 3 - 91 <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 112 N ❑ ❑ <br />Dispenser 3/4 N ❑ ❑ <br />11 <br />4mm <br />® 2015 1NE­,„ Page 1 Checklist P7 <br />