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40 <br /> Designated Underground Storage T (UST) Operator y ;n <br /> Monthly Visual Inspection Checklist <br /> Facility Name: IQNGCA/Mid City Ca FO Renes I Date: 07114/17 `77,126 2017 <br /> Facihty Address: 13850 Dew ies Road <br /> Lodi Code: 95242 <br /> L HI_ALTH <br /> Desi UST Operator Condu2jT the' on: David Smith m's '° <br /> International Code Council Certification##: 8260473 Expiration Datc:6/7/18 <br /> Signature:David SffM ' _ Phone:( ) 37 <br /> Y-Y IN-No,. A-Not AppBeable <br /> Item mowwwNG PANEL l ALARM HISTORY Y N NA <br /> I Monitonng system is powered on and mi operating mode. ✓ <br /> 2 Monito' system is not currentlyshowfn an alarms or wamin . ✓ <br /> 3 Alarm history reportilog for the previous month is available,and has been reviewed by the ✓ f <br /> Desi ted UST O or.(Attach a tb the alarm history rePorVIO9 to thisform if available.) <br /> 4 thr the prevraus MOntft has tTen resPondedto appro y. ✓ <br /> 5 Sensors located in tank- containment sumps have not alarmed in the pad month. ✓ <br /> 52 List all tank-top sumps where alarms occui7ed in the past month: <br /> Noir:Sampn nhww an alarm has occarred in the past mmath rami be htspacmd welrsa a gaw1ped seavice techntclan respondudW.mad <br /> ppopgrly adab+esses.the cause gfOw alarm.Attach dacunwAladQn verging app wriate supilcr to this ngom <br /> I s is t dnrl;nxord msu/ts in Item 6.Wow. <br /> 178'T SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water, s,and hiisidaws substance.Sensors are located prope y. <br /> Nott:t?saal htspecdons ofsanW is only regalrnl In&amps where an alar-has mriaTed In the past monthfor which then is no se.7wee rerorrl. <br /> Y N Y N <br /> Sump Location: Sump Location: <br /> Stapp Location: _ S Location <br /> S Location �. ��- Sump Location: <br /> 7 Sill containment structures are free of waterdebri and us substance. <br /> Y i N i NA I Y N NA <br /> auk I -Contents: diesel Tank 3-Contents: <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Undsr-di eraser containment areas ere free of water,debris,and hazardous substance.Sensors are located ro i . <br /> Y N I NA I Y ` N f NA <br /> Di user I/2 Dispenser 9/.10 <br /> Dig eraser 3/4Dia nser ___ E <br /> Dispenser S/b --___ _ _� IJis er 13 114 - ^_ <br /> D' user 7/$ Digpenser 15 116 <br /> EM EEBEE <br /> PAPERWO INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. ✓ 09/01/16 <br /> 10 containment tests have been completed within the 'red timeframe. ✓ 09/07/16 <br /> I i S ill containment structure ucket testis was q-1-ted within the ear. we 09/01/16 <br /> 12 Tank tightness testis was completed withinuired timeframe• ✓ <br /> 13 -Line tt ess testing was completed withinreq time ✓ <br /> 14 Other reiredintenance was completed within required timeframe.(List testIntaintenanre itena helmv. <br /> TesWaintenance: <br /> TesWaltttenance. <br /> TestlMalntenance: <br /> FACILITY MNRLOYEE TRAINLNG. Y N NA <br /> 15 Ail ility employees have received the required 2n-de-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. ✓ <br /> Note:Any answer Of . should e ex a comment =non e following page,an w reqs e <br /> follow-up action. <br /> QA/QC APPROVED <br /> 7114/201711:52 AMBrandon B <br /> Page l of 2 November 2004 <br /> REV:5.0 <br />