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�6�®C <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name:Tracy Blvd.Shell Date: 12/22/2010 <br /> Facility Address:3725 Tracy Blvd. <br /> City:Tracy Zip Code:95376 <br /> Designated UST Operator Conducting the Inspection: Brian Dunaha <br /> International Code Council Certification#: 8021436-UC Expiration Date: 12/10/2012 <br /> Signature: Phone:(888)700 EPIC <br /> Y=Yes N=No NA=Not APPRcable <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> EMEM <br /> 1 Monitoring system is powered on and in proper operating mode. ❑D <br /> 2 Monitoring system is not currently showing any alarms or warnings. D <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the D <br /> Designated UST Operator. Attach a copy o the alarm history report/logreportllog to thisform i available. <br /> 4 Each alarm for the previous month has been responded to appropriately. <br /> ❑D <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. <br /> 5a _ List all tank-top sumps where alarms occurred in the past month: <br /> Note: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 /> I sum 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 ofsum s is only requi in sums where an alarm has occurred in thepast month for which there is no service record. <br /> Y N ni <br /> Sum Location: Sum Location: <br /> Sum Location: Sum Location: <br /> Sum Location: Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N I NA Y N NA <br /> Tank 1—Contents: 87 Tank 3—Contents:91 0 <br /> Tank 2—Contents: 89 10 1 1 Tank 4—Contents: Diesel El <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located pro erly. <br /> Y N NA Y N NA <br /> Dispenser 112 Gilbarco MPD 1XI Dispenser 9110 Gilbarco MPD ❑x <br /> Dispenser 3/4 Gilbarco MPD ll Dispenser 11/12 Gilbarco MPD ❑D <br /> Dispenser S/6 Gilbarco MPD D Dispenser 13 114 Gilbarco MPD <br /> Dispenser 7/8 Gilbarco MPD Dis enser 15/16 Gilbarco MPDEm <br /> ❑D <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. E 12/22/2009 <br /> 10 Sec dary containment tests have been completed within the required timeframe. ❑x 06/07/2010 <br /> 11 Spill containment structure(bucket)testing was completed within the past year. 1XI 12/22/2009 <br /> 12 Tank tightness testing was completed within required timeframe. ❑D <br /> 13 Line tightness testing was completed within required timeframe. El <br /> 14 1 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below. <br /> Test/Maintenance: Air Quality 3/05/2010 <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facilit em to ees have received the required on-theJob training within the past year. El <br /> 16 1 All facility em to ees hired within the gast 30 days have received the re uired on-the job training. D <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Page 1 of 2 <br />