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HW/O#.l 170316-201 <br /> Designated Underground Storage Tank(UST)Operator D <br /> Monthly Visual Inspection Checklist <br /> Facility Name: ICINGCA/Mid City Ca FO Rexen Date: 04/19/17 L L� 4 E ' 0 1,� <br /> Facility Address: 13850 Devries Road <br /> City: Lodi Code: 95242 <br /> Desi UST Conductinthe' on: David Smith 13,01 NIL <br /> ' ' ` ��-� HEALM <br /> International Code Council Certification M 8260473 /ration Date:6/7/18 <br /> Signature:,David Smith Phone:(M 5884037 <br /> Y s Yee,N-yo,,IA- oIA#VIIesbIe <br /> Item MONITORING PANEL!ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and to proper operating mode. <br /> 2 Monito tem is not currently' showing My alarms or <br /> 3 Alarm history report4og for the previous month is available,and has been reviewed by the <br /> Desi UST 9gerator.(Attach a co f-the alarm histo2 MwrVlogto tkisforot if aratlable. <br /> 4 ' Each alarm for the previous month Im been responded to appropriately. ' <br /> 5 Senors loc and in tank containment IMM have not alarmed in the month. ✓ <br /> Sa List all tank-top stomps where alarms occurred ht thepast month.- <br /> Now <br /> onth:Note:Sumps stem a an alai-has occurred in the pant month must be ftWected unless a 9=41e+d swam technician responded to.and <br /> ps aperlyaddrexse�the cavae tf the alarm.Attach documottadon♦wt5iag appropriate service to das rtwm <br /> Ifs tion is M record n:sulb in item b,blo-lo <br /> 6 -top containment sumps are o water,&W su ce. ensors am located properly—. <br /> IIIAble.l7suat inspection ofsumyn Is only repufred to sumps whereas alarm lues occurred in the post mwuh for whk-h theta Is no senlew rtroti <br /> Y---N- Y N <br /> Sump Location: Stamp Location: <br /> amp Location: Sum Location: <br /> S Location: p ovation: <br /> 7 Skill containment structures are free of water debris.and hazardous substance. <br /> Y t N JI NA I Y N I NA <br /> onten&. diesel le <br /> 3-Contents: <br /> Tank 2-Contents: I I Tank 4-Contents: <br /> 8 112k-diMEw containment areas are fine of water,debris,and hazardous substance.Sensors are located rl <br /> Y N NA Y N NA <br /> mer 112 Dis cser 9/10 <br /> Dis <br /> 314 Dis mer 11/12 �-- <br /> DLs er ST 6 _ Dispenser 13/14 <br /> DIVenser 7/8 _ �)ispenser 13/16 <br /> 1 11 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 tvionitoring system ce nation has been withinpast 12 months. + 09/01/16 <br /> 10 containment tests have een com n the regal tip ✓ 09/07/16 <br /> ll s '1 containment structureucket testing was leted within thepa,yw ✓ 09/01/16 <br /> 12 Tank ti tness tcst was completed within Mqarred timeframe. ✓ <br /> 13 Line tightness testing was completed within required tun e. ✓ <br /> 14 1 Other required testinWinaintenance was com'leted within fired timeframe. ist test/maintenance items below) <br /> TeWMaintenance. <br /> Test/Maintenance: <br /> Test/Maintenanm. <br /> FACILITY EMPLOYEE TRAINING Y N !A]15 All favi// to ees have received the aired an-the-ob traininwithin the t ear.16 All facility employees hired within the past 30 days have received the required on-the-Job training. <br /> Note: ay answer o "N"-s-u- a eap a comment on on"Moillo—wing page,and will require <br /> follow-up action. <br /> QA/QC APPROVED <br /> 4119/20174:44 PMBrandon B <br /> Page I of 2 November 2004 <br /> REV:5.0 <br />