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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY VISUAL INSPECTION CHECKLIST <br />Facility Name Quik Stop Market #1 � � ® ��//i � � Date March 10, 2017 <br />Facility Address 1153 Lincoln Blvd. <br />City, State, Zip Tracy, CA 95376 <br />Designated Operator Harold Largo OCT 2 0 2017 <br />ICC Certification # 8293993 Expiration November 4, 2018 <br />Signature �,,,.t� P <THEALTH Phone (916) 373-1166 <br />MIRWOM <br />[5aList <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />. _r, ". t ��_ oringsystem is powered on and in proper operating mode. ■ ❑ ❑oring system is NOT currently showing any alarms or warnings. ■ ❑ ❑ history report / log for the previous month is available, and has been reviewed by the Designated UST Operator. ■ ❑ ❑ copy of the alarmhistory report /log to this form?alarm for the previous month has been responded to appropriately.❑❑■ors located in tank -top containment sumps have NOT alarmed in the past month. ■ ❑ ❑t all tank -top sumps where alarms occurred in the past month: <br />: 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 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 N <br />Sump Location: ❑ ❑ Sump Location: ❑ ❑ <br />Sump Location: ❑ ❑ Sump Location: ❑ ❑ <br />Sum Location ❑ ❑ Sump Location ❑ ❑ <br />P , W _ _. w �__. . <br />7 Spill Containment Structures are free of water, debris, and hazardous substance. <br />Y N NA Y N NA <br />Tank 1 - 87 ■ ❑ ❑ Tank 3 - 91 ■ ❑ ❑ <br />Tank 2 - 89 ■ ❑ ❑ <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 ■ ❑ ❑ <br />Dispenser 3 / 4 ■ ❑ ❑ <br />0 2017,.: w Page l Checklist P1 <br />