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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY VISUAL INSPECTION CHECKLIST <br />Facility Name Quik Stop Market #� <br />April 11, 2017E <br />Facility Address 1153 Lincoln Blvd. C;6 E V � �Date <br />City, State, zip Tracy, CA 95376 <br />Y N <br />Designated Operator Harold Largo OCT 2 0 2017 <br />N <br />Sump Location: ❑ ❑ Sump Location: <br />ICC Certification # 8293993 Expiration <br />November 4, 2018 <br />Sump Location: 11 E] Sump Location: <br />Signature ��/�� ENVIRONMENTAL HEALTH Phone <br />(916) 373-1166 <br />Sump Location. R _❑ ❑ Sump Location: _..._ u _ <br />MONITORING PANEL / ALARM HISTORY <br />Item:Sumpswhere <br />Y N <br />NA <br />1 Monisystem is powered on and in proper operating mode. <br />0 ❑ <br />❑ <br />2 Monisystem is NOT currently showing any alarms or warnings. <br />❑ <br />❑ <br />3 Alarry report / log for the previous month is available, and has been reviewed by the Designated UST Operator. 0 ❑ <br />❑ <br />3a Is of the alarm history report /log to this form? -- --- - <br />❑ <br />❑ <br />4 Each for the previous month has been responded to appropriately. <br />❑ ❑ <br />5 Senscated in tank -top containment sumps have NOT alarmed in the past month. <br />N ❑ <br />❑ <br />5a Link -top sumps where alarms occurred in the past month: <br />Dispenser 3 / 4 m ❑ ❑ <br />Notps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br />erly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />m 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 <br />Y <br />N <br />Sump Location: ❑ ❑ Sump Location: <br />❑ <br />El <br />Sump Location: 11 E] Sump Location: <br />❑ <br />❑ <br />Sump Location. R _❑ ❑ Sump Location: _..._ u _ <br />.a.. ❑ <br />❑. <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 M ❑ ❑ Tank 3 - 91 <br />0 <br />❑ ❑ <br />Tank 2 - 89 E ❑ ❑ <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 0 ❑ ❑ <br />Dispenser 3 / 4 m ❑ ❑ <br />0 2017_�:------ - Page l Checklist P1 <br />