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40 40 <br /> W/p#; 170403-548 <br /> Designated Underground Storage Tank(UST) Operatir ED <br /> Monthly Visual Inspection Checklist <br /> , <br /> Facility Name: KINGCA/Mid City Ca FO Regen Date: 05/08/17 <br /> Facility Address: 13850 Devries Road " <br /> Hit <br /> City: Lodi Zi Code: 95242 <br /> Desi ated UST 22crator C2RLu In the in ection: David Smith '_ T <br /> International Code Council Certification#: 8260473 iration Date:6/7/18 '' <br /> Signature:David Srrdth Fhace: ( }5 7 a s h <br /> Y Yee,v=No,SIA at Applicable <br /> Item MONITORING PANEL/ALARM BLSTORY Y N NA <br /> I Monitoring system is pwere,on and in proper operating mode. <br /> 2 Monitoring system is not currently showin !ny alarms or warm <br /> 3 Alarm—M—dory repo ag ort the previous mo is available,an been reviewed by the <br /> Desi ted UST Operator.(Attach a co /" the alarm history reportAbg to this orm i arailable.) <br /> 4 Each alarm for the previous month hu been responded to approp ate �► <br /> 5 Sensors located in - containment sum a not alarmed in the past month. eE - <br /> Sa List all lank-top sumps where alarms occurred in the past month: <br /> ,Vote.Sunym w,+ere an alarm has ocrarrtd in thepast month must be inspexted unless a qua!{Jiedservice reelurktan responded to.and <br /> prwti ll•addresses,the carpe a fthe akam.Attach docetmentatlon ttv(f ft app wprlak•ser►,cv to dib n port. <br /> !J ensu tba <br /> It aWlirecard rrsuhs in Item 6.below. <br /> U S TEM INSPE 1 N <br /> 6 -top contatsnnent sumps are Fee o water,Nfifis,sa us su tante.Sensors are located props y. <br /> Note:Muat inspeedons ofsungrs is only nV idre d fn simips where an alarm has occurred in the past month for",rich there is no sen toe recant. <br /> Y N Y N <br /> SUMP Sumplocation: <br /> «tip ocation Sump Location: <br /> Sump Location: tip Location: <br /> 7 SRW containment structures ate free of water debris,and hazardous substance. <br /> Y N NA I Y N 11A ; <br /> Contents: diesel ✓ Tank 3-Contents: <br /> Tank 2-Contents.- Tank 4-Contents: <br /> 8 Under-dis enser containment areas are free ofwater,debris,and hazardous substance.Sensors are located <br /> Y N NA Y rN NA <br /> Di user <br /> 112 <br /> Dis user 9/10 <br /> Dis er 3 14 <br /> Dispenser 11112 <br /> Dispenser 5/6 ----_ Dispenser 13/14 ----��—�– <br /> Dispenser 7/8 _—__--- _ -- Dispenser <br /> 30M 1111 1 <br /> PAPERWORK INSPECTION Y N INA DATE DONE <br /> 9 nrtormg system ce rcatnon M been completed MiG past 12 months. se ; 09/01/16 <br /> 10 Seen containment tests ve been nomlR@ wtihm the required timeframe. ✓ 09/07/16 <br /> 11 Spill containment structure ucket)testing was completed within the ear. 09/01/16 <br /> 12 Tank tress testin was co re completed within sired timeframe. ;T oe' - <br /> 13 Line tightness testing was completed within required time rime. <br /> 14 Other required testin aintenance was cam Ieted within required timeframe. List test/maintenance items below. <br /> TesUMaintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility em 12 ees have received the Leguired on-the-job training within the past year. ✓ <br /> 16 All facility employees hired within the past 30 days have received the required on-the-Job training. d <br /> ote: Any answer o shoura se exp n int a eonunent SFCFOB on trw, o owing page,and wilreqs re <br /> follow-up action. <br /> QA/QC APPROVED <br /> 518/201712:18 PMBrandon B <br /> Page 1 of 2 november 2004 <br /> REV:5.0 <br />