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Designated Underground Storage Tank,,!!US/�■��y/ Operator <br /> Monthly Visual Inspection Checklist <br /> FacilityName: KINGCA—Mid City Ca FO Remen Date: 201 > _rr <br /> Facility Address: 13550 Devries Road <br /> Ci : Lodi Cade: 95242 <br /> Designated UST Operator Conduetinthe inspection: David Smith G s 1 I °7'° - LT H <br /> International Code Council Certification#: 8260473 Fxpimtion Date:2018-0647 NT <br /> signature:DavW Smith " Phone: 888 5884737 <br /> Y=Yes,IN-No%N*. A-- otApplicable <br /> Item MOMTOWNG PANEL/ALAILM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in proper operating mode. be <br /> 2 Monitoring system is not curmnlly showing any alarms or warniin . ✓ <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the ✓ <br /> Desi ted UST 2perator. Attach a co (if the alarm history reportoft to thisform if available. <br /> 4 alarm tor the previous month has been responded to appropnate y. _ ✓ <br /> 5 Sensors located in tank to containment sumps have not alarmed in the Rmt month. ✓ <br /> 5a List all tank-top sumps where alarms occurned in the past month: <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a quatdiext service to cluticlan re5pondeaf ta.and <br /> properly addresses,the carate q/Yhe alarm.Attach documentation sveyiing appropriate,senice to this n port. <br /> !J's Milan isnacard results in Item 6 below. <br /> M9 awmmmvm <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance.Sensors are located properly. <br /> Note:17suat hapecdons ofsumlas is only required in suneps where an alarm has occurred in the past month for a hteh there is no service reword. <br /> Y N Y N <br /> Sump Location: Swnp Location: <br /> Sump Location � Su Location: <br /> Surra Location: SumpLocatian: <br /> 7 Spill containment structures are free of water debri and hazardous substance. <br /> 1 Y N NA Y N NA <br /> Tank 1 -Contents: diesel ✓ i Tank 3-Contents: <br /> Tank 2-Contents: I Tank 4-Contents: <br /> S Under-dispenser containment areas are free of water,debris,and hazardous substance.Sensors are located pro eel . <br /> Y N NA Y N NA . <br /> Dispenser 1/2 Dir er 9/10 <br /> Dispenser 3/4Denser 11/12 <br /> Dispenser S/6 Dsspenser 13 114 <br /> Dispenser 7l8 __— — — Dispenser 13/16 <br /> PAPERWORK INSPECTION JY N NA DATE DONE <br /> 9 Monitoring system certification has been completed within past 12 months. be 2015-0-6 <br /> 10 Seco containment tests have been completed within the mlWred timeframe. be 2013-09-12 <br /> 11 S ill containment structure(bucket)teging was completed within the past year. ✓ 201549-03 <br /> 12 Tank titness testing was co feted within aired timefi-ame. ✓ , <br /> 13 Line tightness testing was completed within required timeframe. ✓ <br /> 14 Other re iced testis intenance was corn feted within nNuired timeframe, ist test1n, tenance items below. <br /> Test/Maintenance. <br /> TestlMaintenance: <br /> Test/Maintenance. <br /> FACILITY EMPLOYEE TRALNING JY N NA <br /> 15 All ility em 10 ees have received the required on-the-'ob training within the past year. ✓ <br /> 16 All facility employees hired within the past 30 days have received the required on-the-Job training. 1 ✓ <br /> Note:Any answer-of s n a eap a t o comment sec n on t e oo ng page,an require <br /> follow-up action. <br /> QAIQC APPROVED <br /> 8/21201612:36 PMBrdndon B <br /> Page 1 of 2 November 2004 <br /> REV:5.0 <br />