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0 • <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />W/O#: 150310-404 <br />Facility Name: KINGCA— Mid City Ca FO Re en <br />Date: 4-2-2015 <br />Facility Address: 13850 Devries Road <br />City; Lodi <br />Zi Code: 95242 <br />Designated UST Operator Conducting the inspection: David Smith <br />Intematio 8260473 <br />Si afore:Phone: <br />Expiration Date: 6-7-2016 <br />888-588-8737 <br />V-UV616V IV VI,W.VV Y-Yei,NiNO, PIA—NOTA DCaDle <br />Item MONITORING PANEL / ALARM HISTORY Y N NA <br />1 Monitoring system is powered on and in proper operating mode. ✓ <br />2 Monitoring system is not currently showing any alarms or warnings. ✓ <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the ✓ <br />Designated UST Operator. (Attach a copy (if the alarm history report/log to this form if available.) <br />4 Each alarm for the previous month has een resp -on to appropriately. <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month. ✓ <br />5a - List all tank -top sumps where alarms occurred in the past month: <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a quaked service technician responded to, and <br />property addresses, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />tfsump Inspection is remfired record results in item 6 below. <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspections ofsumps is only required to sumps where an alarm has occurred in the past month for which there is no service record <br />Y N Y N <br />Sump Location: Sump Location: <br />Sump Location: Sump Location: <br />Sum Location: Sump Location: <br />7 Spill containment structures are free of water, debris and hazardous substance. <br />Y N NA I Y I N INA <br />Tank 1 - Contents: diesel ✓ Tank 3 - Contents: <br />Tank 2 - Contents: Tank 4 -Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are locatedpropY. <br />Y N NA Y N I NA <br />Dispenser 1 / 2 Dispenser 9 / 10 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser 5 / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 1 Dispenser 15 / 16 <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. ✓ 9-11-14 <br />10 Secondary containment tests have been completed within the required. timeframe. ✓ 9-12-13 <br />11 Spill containment structure(bucket) testing was completed within the past year. ✓ 9-11-14 <br />12 Tank tightness testing was com leted within required timeframe. ✓ <br />13 Line tightness testing was completed within required timeframe. ✓ <br />14 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING YEVV <br />15 All facilityemployees have received the required on-the-job trainingwithin the past year. ✓ <br />16 All faeility employees hired within the past 30 days have received the required on -the -Job training. <br />Note: Any answer of 'IN" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />QA/QC APPROVED <br />4/8/201512:47 PMJus'tin Tre <br />Page 1 of 2 3 `'J 17 2 015 November 2004 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />