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IW/O#.l 161213-449 <br /> C .Designated Underground Storage Tank(UST) Operator r ' <br /> jV <br /> Monthly Visual Inspection Checklist . <br /> Facility Name: IUNGCA-Mid City Ca FO ReRen Date. 01/19117 <br /> Facility Address: 13850 Devries Road <br /> City: Lodi Cade: 95242 <br /> Designated UST 2paator ConduELMS the inspection: David Smith <br /> Iinernational Code Council Certification#: 8260473 Expiration Date:617118 i a ` a.i° i HEALTH <br /> Iff <br /> Si turc:David Smith Phone: =I 588-8737 ._a 5 a <br /> Y Yee,N No,SIA at AppNesible <br /> Item MONTTf)RING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in pMer operating mode. ✓ <br /> 2 Monito' ! stem is not currently sho ' an alarms or warnin ✓ <br /> 3Alarm history reportflog for the previous month is available,and has boxm reviewed by the ✓ <br /> Desi ted UST 2gemtor.(Attach a rifthe alarm Mitory report/logreportflog to this rm i available. <br /> 4 a arm r e pre ous mont n resp to approp ate y. ✓ <br /> 5 Sensors located in tank-Wp containment st larmed in the month. ✓ <br /> 58 List all tank-top sumps where alarms occurred in the past month: <br /> Vote:Sumps is here an alarm h'ats�mvurnad is the past mantis smut he inspected usik=a qual{fled sendre to amician revonvial to.and <br /> properly addresses.the cause gfthe alarm.Attach datums<ntaNan swoIng appropriate sendre to this mpam <br /> l sum tion is t eQ encs ord trsuhs is tkm ffy lxlnnv. <br /> SYSTEMUST INSPE I <br /> 6 -top containment sumps are free of water,debris,an us su ce. ensors are Io&W props y. <br /> 1Moter nand inspec:dons ofsuaw is only rrquir sd in sumps where-an alarm has accursed!n the past mashfar si*kh there is no senice re:aord <br /> Y i N Y v <br /> Sump Location: I Sump Location: <br /> fi.__ <br /> Sump Location: Sum Location: <br /> Sump Location _,... Saanp Location: <br /> 7 Spin containment structures are free of water.debris.and hazardous substance. <br /> Y N NA 1 Y N NA <br /> ontents: diesel ✓ Tank 3-Contents: <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Under-d' nor contisinment areas are free of water,debris,and hazardous substance.Sensors are looted rl . <br /> Y N NA Y ' y I NA <br /> Di er 1/2 Diwnser 9110 <br /> Dispenser 11/12 _ <br /> Drier S I6Dispenser 13/14 <br /> Dispenser 7/87 Dispenser 15/16 <br /> EEO <br /> PAPERWORK INSPECTION Y N NA I DATE DONE <br /> 9 Monitoring system certi ication cen z;ip-e-wmi past 12 months. ✓ ° 09/01/16 <br /> 10 Secondary conudurnent tests have been comp within the requi timeframe. ; td s 09/07/16 <br /> _Ll_ §jill containment structure bucket`te!!jR&tea!' was R2TPIeted within the ear. ✓ 09/01/16 <br /> 12 Tank titness testing was completed within re'' fired timefimne. yr-t <br /> 13 Line tightness testing was completed within requirud time e. ✓ <br /> 14 Other re iced tedingAnaintenance was cam ted withinTguired timeframe. List test/maintenance items below. <br /> Test/Mainterutnce: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y Y NA <br /> I S All facili to ees have received the wired 22 he-job training within the est year. ✓ <br /> 16 All facility employees hired within the past 30 days have received the required on-the-Job training. <br /> ote:lay answer-ol"511 s=13 Ge e:p a comment sec on on'll;Following page,and will require <br /> follow-up action. <br /> QAIQC APPROVED <br /> 1120120178:53 AMBrandon Bo <br /> Page 1 of 2 November 2004 <br /> REV:5.0 <br />