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y,. W -478 DI <br /> Designated Underground Storage Tank(UST) Operator "J, <br /> Monthly Visual Inspection Checklist <br /> Facility Name: KINGCA-Md City Ca FO Regen Date. 1-2/19/16 r <br /> T $ <br /> Facility Address: 138so Devries Road <br /> Ci ; Lodi Zip Code: 95242 <br /> Designated UST Operator Conductin the inspection: David Smith r a" ®<4 . T <br /> International Code Council Certification#: 8250473 Expiration Date.6/7/18 ��', � ` T <br /> Signature:David Snft Phone:(888)588-8737 <br /> Y=Ya,K a 1Ie,llA a Net cable <br /> Item MONITORING PANEL/ALARM.ARM HISTORY Y N NA <br /> MEIMEmum <br /> I Moni�ntc �na:rgid� ���,de. <br /> 2 Marnin3 arm ,and has sen reviewed by <br /> Desi UST Operator.(Attack a copy(fthe alarm history repoWlbg to thisform i available. <br /> 4 atmfor'the previous mo een responded to appropriately. ✓ <br /> 5 Sensors located in tank t containments a not alarmed m the month. <br /> 5a List alUank-top sumps where alarms occurred in the past month: <br /> Now:Sumas where an alarm has occurred in the part month mast be Inspected unless a qualildarl st n ke techedcdan responded to.and <br /> -addresxes,the carie grthealarm.Attach documenw don zrr#ft opprWriale strvdce to this ripam <br /> I:s lion it n record results in item 6,Mow <br /> URI IO <br /> 6 -top containment sumps are free o waxer,deW,and hazardous s-50ensors are oca pmpe y. <br /> Now:r renal dnsperdons a(minNr Is only rcqudre d In stmrps where an alarm has occiamd In the past month for which there Is no service record. <br /> Y N Y N <br /> Sump Location: Utonpp <br /> ocation: <br /> umpLocation ocation: <br /> S Location: _ - ocation 7 S rill containment structures ane free ofwater debri and hazardous substance. <br /> Y N] NA : Y N NA <br /> onterits: diesel ✓ i Tank 3-Contents. <br /> Tank 2-Contents: I I Tank 4-Contents: <br /> 8 Under-g!!peser containment areas are free of water,debris,and hazardous substance.Sensors are located l . <br /> Y N NA Y N ; NA <br /> Di user 1/Z 11Die user 9/10 <br /> Dis er 314 _ Domer 11/12 <br /> Dac er 13114 <br /> Dispenser 718 Dispenser <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring system c cation s wr past 1 mons ✓ 09101!16 <br /> 10 Secondary containment tests have been completed within the requi timeframe. ✓ 09/07/16 <br /> ll Spill containment structure ucket testingwas completed within the t year. ✓ 09/01116 <br /> 12 Tank tightness testingwas convicted within timeframe. y <br /> 13 me tl ess testing was comp withrn requir tune e. ✓ , <br /> 14 Other required testin` intenance was leted within iced timeframe.(List tesdmaintenance items below. <br /> TestlMaintenance: <br /> Test/Maintenance: <br /> TesI Maintenance.* <br /> 210 ga 11 IN III 1 01 <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facilit 1 ees have receivedEMPLOYEE the required on-the-job train!M within the past year. tt' <br /> 16 All facility employees hired within the past 30 days have received the required on-the-Job training. ✓ <br /> Note:Any answeriTV s e exp t e comment s on on trw WN-Ang page,and will require <br /> follow-up action. <br /> QA/QC APPROVED <br /> 121191201611:06AMBrandon B <br /> Page 1 of 2 November 2004 <br /> REV:5.0 <br />