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Designated Underground Storage Tank(UST) Operator , <br /> Montlily Visual Inspection Checklist <br /> Facility Name: KINGCA/Md City Ca FO Regen Date: 03127/17 u� I <br /> Facility Address: 1385#Devrin Road <br /> City: Lodi Code: 95242 _ s <br /> Desi UST Operator Conductingthe inspection: David Smith t,,1,,j �b s �-�,, � HEALTH <br /> FInternational Code Council Certification#: 826#473 Fx iration Date:6/7/18 r NT <br /> Si lure:David Smith .-.- Phone: (888)588-8737 <br /> Y=Yes,N ffi No,VA- -at-AwNeable <br /> Item MONITORING PANEL/ALARM HISTORYMM Y t- NA <br /> 1 Monitoring tem is powered an aid' properoperatin" mode. y <br /> 2 Monitoring stem is notcern soli sho anyalarms.or warnin <br /> 3 Alarm istory rep art/togthr the previous month is available,and has been reviewed by the <br /> Designated UST .(Attach a copv afthe alarm history repormiog to this orm if available,) <br /> 4 atm for the previous month has been responded to appropriately. <br /> 5 Sensors located in tank containment sum have not alarmed in the past month. <br /> 5a List all tank-top sumps where alarms occurred in the past month: <br /> Nine:Sumps n•lury an alarm has mwarrad in rhe past monde nest be h&wccted antes aqua4fied service technician responded to.and <br /> PrW-&4d&rsw.%the carni ofthe alarm AM*dacamentudon I-V.dng opp Wriate.scrvtca to dds nVm% <br /> sranp Nott Ls t�gtttmml rveard rwuks in Ilam 6.below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are fice o water, us su ce.Sensors are located props y. <br /> Note:d?saad hwpecdons afsamps Is only required in sumps nher+e an alarm has occurred hi thu past monthfor which duce is no sen ice mord <br /> Y N Y N <br /> Sump Lavation: Sump Location: <br /> Sum Location: <br /> p ___.___.,..... .._..._..._. .__._, ___ Sum Location: <br /> Sum Location: Sump Location: <br /> 7 S ill containment structures are free of water debris.and ha2ardous substance. <br /> Y 1 N NA IY ?Y I NA <br /> Tank t -Contents: diesel ✓ Tank—3-Consents: <br /> Tank 2-Contents: . Tank 4-Contents: <br /> —4- <br /> 8 Under enter contaimnent areas are free of water;debris,and hazardous substance.Sensors are located properly. <br /> Y N NA I I Y I N NA <br /> j <br /> Dispenser 112 Drs user 9/10 <br /> Dispenser 3/4I Dispenser 11112 <br /> Dispenser S/6 '-� D�rer�ser 13 114 — <br /> Dispenser <br /> 15116 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 nrtoring system ce rtification has been comp et wr past 12 months. z ✓ ? 09l01/16 <br /> 10 Secondant containment tests have been completed within the required timeframe. ✓ 09/07/16 <br /> 11 Spill containment structureueket tag!gg was con Ieted within the past year, 09/01116 <br /> 12 Tank d tness testin was completed within Muired timeframe. a/ <br /> 13 Line tightness testing was completed within requhQ time e. <br /> 14 Other required testis intenance was completed within required timefiame. est tesdmaintenancertems belmv. <br /> Test/Maintenance: <br /> TestlMantenance: <br /> TestlMaintemmce: <br /> FACILITY.EMPLOYEE TRAINING Y N NA <br /> r-15--1 All facile employees have received the Muired on-the-job traming within the past year. s/ <br /> I6 All facility employees hired within the past 30 days have received the required on-the-Job training. <br /> ote:Any answer o . should be explained in the comme-n-fisjjjFbi on the following page,an w requ e <br /> follow-up action. <br /> QA/QC APPROVED <br /> 3127/20172:54 PMBrandon B <br /> Page t of 2 November 2004 <br /> REV:5.0 <br />