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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY VISUAL INSPECTION CHECKLIST <br />Facility Name <br />Facility Address <br />City, State, Zip <br />Designated Operator <br />ICC Certification # <br />Signature <br />Quik Stop Market #1I \ / r V <br />1153 Lincoln Blvd. r .� V L... <br />Tracy, CA 95376 OCT 2 0 2017 <br />Harold Largo <br />8293993 <br />ENVIRONMENTAL HEALTH <br />Date June 12, 2017 <br />Expiration November 4, 2018 <br />Phone (916) 373-1166 <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free —of 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: ❑ ❑ 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 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 1 /2 0 ❑ ❑ <br />Dispenser 3 / 4 E ❑ ❑ <br />4mm <br />02017 r E71-1� Page 1 Checklist 131 <br />