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• z <br /> Designated Underground Storage Tank(UST) Operator �� r ' � � <br /> Monthly Visual Inspection Checklist ' � <br /> Facility Name: KINGCA-Mid City Ca FO Reagin Date: 11/14/16 - <br /> Facility Address: 13950 Devries Road <br /> C' : Lodi Zip Code: 95242 ,f rEALT <br /> DesiE2ated UST Operator Conducting the' ection: David Smith ._ p` <br /> International Code Council Certification#: 8260473 Expiration Date 6/7/19 " <br /> Si tore:David Smfth Phone: 888)5884737 <br /> Y-Yes,N—No,NA a Not AppReable <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is powered on and in I mode. ✓ <br /> 2 Monito ' tem is not currently show' an alarms or ✓ <br /> 3 Alarm history reportflog for the previous month is available,and has been reviewed by the ✓ <br /> Desi ted UST 9pgator.(Attach a copy ffthe alarm histore ort/!o to this form i mailable.) <br /> 4 Each alarm fix the previous month lias been responded to appropriately. a/ <br /> 5 = Sensor's Dated m - containment!!M have not alarmed in the montlt. ✓ <br /> 5a List all tank-top sumps where alarms occurred in the past month: <br /> Note:Swnps s hwr an alarm has ocewrevd tet the pant mondt must be inspected wiles a gual ffied servic a te+chnlclat responded 1o.and <br /> ,properly addressm the caeuc of the ahwm Attach dacumentadon srr wag appropriate service•to this nVam <br /> =1» tkw is t cgrd+Yd mord natdts in!lean 6.be law <br /> 911192210111 ST SYSTEM IMNSPECCrIC... <br /> ti T top containment sumps are ee-of water, an us su lance.Sensors are grope y. <br /> Nate;17su d hupecdons of sumps is only requbvd in stanps wheevan alarm has returned in the past month for which dhrre is no sen•tce rrcwd. <br /> Y N I Y N <br /> Sum Location: Sump Location: <br /> Sump Loadon <br /> _. __r.,.. Sum Location: <br /> SumSum Lacation _.t p ocation <br /> 7 Sill containment structures ane free of water de and hazardous substance. <br /> Y N NA ' Y N NA = <br /> Contents: diesel ✓ r Tank 3-Contents: <br /> Tank 2-Contents: I Tank 4-Contents: <br /> 8 Under-Loonser containment areas are free of waster,debris,,and hazardous substance.Sensors are located <br /> Y N NA I Y ' :Y NA <br /> RiTemer1/2 DiWenser9/10 <br /> Die er <br /> 314 _ Die user 11112 <br /> Die er 5/6 Dispenser 13 114 <br /> DLVenser7/8 _ - Dtsi peatser 15/16 <br /> 21 saugggsa2sm <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 mtormg system certification has been compleQ within past 12 moat ✓ 09/01/16 <br /> 10 Seco2qm containment tests have been completed within the required timeframe. ✓ 09/07/16 <br /> 11 S 'l containment structure cket les' was co leted within the ear. ✓ 09/01/16 <br /> 12 Tank ti tease testis was co leted within 'uired timeframe. ✓ j _ <br /> 1atesting was completed within requiredtmeme tt ✓ <br /> 14 Other reg#Td testinglMaintenance was corn laced within iced timeframe. List te-ulmaintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance. — <br /> TestlMaintenwwe: <br /> MEM <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 Alt faeiti 1 ccs have received the required on-tbe-'tib trainin within the past year. be <br /> 16 All fitcility employees hired within the past 30 days have received the required on-the-Job training I ✓ <br /> Note:Any answer R"IN11'sRuild 5e RxIpMn7n Me comment secHou on trw o ovr ng page,and w require <br /> follow-up action. <br /> QA/QC APPROVED <br /> 11/14/201610:39A randon B <br /> Page 1 of 2 November 2004 <br /> REV:5.0 <br />