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00 00 <br /> 1 <br /> Designated Underground Storage T (UST) Operator� E D <br /> Monthly Visual Inspection Checklist <br /> Facility Name: KINGCA/Mid City Ca FO Ret en Date. 06/12/17 vs <br /> Facility Address: 13850 Devries Road <br /> City: Lodi Zip Code: 95242 LTH <br /> Desi UST erat"Con&2tiE&the' ection: David Smith <br /> Imernational Code Council Certification##: 73 Expiration Date:6!7/18 0 -TF 3 T <br /> Signature:David Smith Phone:(888)58848737 <br /> Y—Yes,NNo,;YA-Nat Appdeable <br /> Item M0NIT0RING PANEL/ M9T0RY Y N Ism <br /> NA <br /> I Monitoring s 'tem is' wered on and in operating mode. <br /> 2 Monito ' system is not currently sho ' analarms or <br /> 3 tory reps og or a previous mon >s a e,and has been reviewed by die <br /> Desi ted UST Q erator.(Attach a co the alarm histo WYV?og to this rm i available.) <br /> 4 FAch alarm thr the previous month has been responded to approp <br /> 5 Sensors located in tank containments a not all dinthep±Lamon9i. t r <br /> 5a List all tank-top sumps where alarms occurred in the past month: <br /> Nate.Sumps Wavy an alarm has accurnd in the parse month mast be brapected wrlaas a qualltled sevtce tecludctan responded to.awl <br /> pnaper6,add►e=,j.the evuw gnYhealarrn.Attach documentadwt♦trtfjdag appropriate senicc to this rtpan <br /> tf tan is nvard results In lam 6.bUmv. <br /> U <br /> 6 T p containment sumps are of water,WK an ous substance.Sensors are locatR props y. <br /> Note tImal k"PwUans afmmps is only regrdrat In sumps where as alarm has aacwrrd in the past moarh./ar rddch there is na sender reearr4 <br /> Y INI Y N <br /> Sump Location Sump Locatlon <br /> i <br /> Y&;V— <br /> LurV Location: - Location <br /> 7 S till containment structures are free of water 0 is.and ous substance. <br /> Y N NA YI N —NA— <br /> Man <br /> I ontents: diesel Tank 3 Contents: <br /> Tank 2-Contents: Tank 4 Contents: <br /> 8 Under-dispenser c=Wmnent arm are free of water,debris,and hazardous substance.Sensors are located properly. <br /> Y N NA Y I1 NA <br /> 2§pMM 1/2 DImwerg/10 <br /> Disimaera/4 Die erld/12 <br /> Dispenser S!b Dispenser 13 1d4 <br /> Dispenser 7/8 I1tspower IS 116 <br /> 1 <br /> PAPERWORKE4WECTION Y N NA DATE DON <br /> 9 Monitor tng system ceREWIon his been completed wr past 12 months. ✓' 09/01/16 <br /> 10 containment tests have been c-olijEQ within the dred,timeframe. a+' 09/07/16 <br /> 11 1 containment structure(bucket)tes was eo leted within the past year. r/ 09/01116 <br /> 12 Tank d eases testing was completed within required timeframe, <br /> 13 Line tightness testing was completed wiiWn Rif=NQ timeframe. <br /> 14 Other required testingimaintenance,was completed within r timeframe. ist test/nulintelum items below. <br /> Te"aintenance. <br /> Test/Mairdenance: <br /> Test/Ma&itenance: <br /> FACILITY EMPLOYEE TRADUNG Y I-IN NA <br /> 15L-Ay <br /> ll facilityemployees have received the r th'red an- e-'ob fret ' within the t year. a✓ <br /> 16ll facility employees hired within the gest 30 days have received the required on-the-Job training. e0 <br /> ote: answer o s ou d be ex t o comment n on t o aria ng page, ;Rulre <br /> follow-up action. <br /> QA/QC APPROVED <br /> 6113/20173:46 PMBrandon B <br /> Page 1 of 2 November 2004 <br /> REV:5.0 <br />