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W/O#. 170123-399 <br /> °. <br /> Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: KLRGCA-MId City Ca FO Reaen Date: 0212V17 <br /> Facility Address: 13850 Devries Road <br /> City: Lodi Zip Code: 95242 <br /> Desi stet UST 2peratw Conductia the inspection: David Smith d, \L HEALTH <br /> International.Code Council Certification# 8260473 Exp iradon Dabs.617/18 <br /> S' :David Srrdth —M:, Phone:(888)5884M7 NT <br /> Y=Y4%N-NN.NA- tAAPPII=bIe <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> I Monito!iRj system is powered on and in proper o erasing mode. ✓ <br /> 2 Monitoring sten is not currentl showing alarms orwarnings. ✓ <br /> 3 Alarm history reportilog for the previous month is available,and has been reviewed by the ✓ <br /> Desi ted UST Operator.(Attach a co (if the alarm histo repordlo to thisform if available) <br /> F5a4 <br /> arm or a previous mon n respondedto appropriately. <br /> ✓ <br /> Sensors located in tank-top containment sumps have not alarmed in the pastmord. ✓ - <br /> List all tank-top sumps where alarms occurred in the past month: <br /> Note.su npe nhe m an alarm has orrurred in the past month must be Inspected unless a gmsIyW service tethnktan nespatded to.and <br /> properl.addranm.the cause afthealarm.Attach documentarian tw#Wng appnWrlale service to tris report <br /> Zteg ion&s rcuordre teks in h m 6.hdow. <br /> -209M IMMm <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,int us substance.Sensors are locatedproperly. <br /> te:Fund inspectors ofsunW Is only required in sumps where on alarm has occurred in the past marthfor x�iich there is no smvtee rMord <br /> Y Er <br /> N Y � <br /> Sum _----Location: Sump Location: <br /> _- _ Y - <br /> Stamp Location: Sum Location: <br /> Sum Location: Sump Location: <br /> 7 S till containment structures are free of water. e 'Sp and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1 -Contents: diesel ✓ I I I Tank 3-Contents: <br /> Tank 2-Contents: i I I Tank 4-Contents.* <br /> 8 Under enser containment area are free of water,debris,and hazardous substance.Sensors are located properly. <br /> Y N NA Y N NA <br /> Dispenser l/Z I Dispenser9110 <br /> Dns eraser 314 Dispenser 11/12 <br /> Dis er <br /> 516 --i_ Dispenser 13 114 — --- <br /> Di nser 7/8 _ Dispenser 15 1,16 -^-- <br /> 31111 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. 6e092/16 <br /> 10 Secondary containment tuts have been completed within the required timeframe. le_the <br /> 11 Spill containment structure ckey was eon tared within the car. ✓ 09/01/16 <br /> t2 Tank tightness testing was completed within timeframe. I ✓ <br /> I3 Line tightness testing was completed within required timeframe. ✓ <br /> 14 Other required testis maintenance was completed within required timeframe.(List test/maintenance items below.) <br /> TesWaintenance. <br /> TestlMabuenance. <br /> Test/Mahntenance. <br /> j FACILITY EMPLOYEE TRAINING I Y I N I NA <br /> 15 All faciii 10 ees have received the required on-the-job trainm within the past year. ✓ <br /> 16 Al facility employees hired within the past 30 days have received the required.on-the-Job raining. ✓ <br /> Note: y answer o s e e a comment' n on t o o ng page,and W uIre <br /> follow-up action. <br /> QAIQC APPROVED <br /> 2121/20173:21 PMBtandon B <br /> Page i of 2 November 2004 <br /> REV:5.0 <br />