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• • W/O#: 1 150406-386 Designated Underground Storage Tank (UST) Operator Monthly Visual Inspection Checklist Facility Name: KINGCA— Mid City Ca FO Re en Date: 5-26-2015 Facility Address: 13850 Devries Road Monitoring system is powered on and in proper operating mode.Monitorin City: Lodi Zip Code: 95242 Designated UST Operator Conducting the inspection: David Smith history report/log for the previous month is available, and has been reviewed by the ✓ Designated UST Operator. (Attach a copy (if the alarm history report/log to this form if available) 1ntematioq#fged1nftWWj 8260473 Signature: 1 Expiration Date: 6-7-2016 Phone: 888-588-8737 VVI LVI LV IV VI .vv.vv Y s Ye& N - No. NA s Not ADDDCADle is mie: Any answer or ••rr•• anouia De ezpiamea in the comment section on me ronowmg page, ana win require follow-up action. QA/QC APPROVED 6/1/201511:03AMJustin Tre Page 1 of 2 - 9 crij ENVIRONMENTAL HEALTH DEPARTMENT November 2004 MONITORING PANEL / ALARM HISTORY Y N NA tI Monitoring system is powered on and in proper operating mode.Monitorin s stem is not currentl showin an alarms or warnings.Alarm history report/log for the previous month is available, and has been reviewed by the ✓ Designated UST Operator. (Attach a copy (if the alarm history report/log to this form if available) 4 Each alarm for the previous month has been respon to appropriate y. ✓ 5 Sensors located in tank -top containment sumps have not alarmed in the past month. ✓ 5a - List all tank -top sumps where alarms occurred in the past month: Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualfed service technician responded to, and properly addresses, the cause of the alarm. Attach documentation ver(fying appropriate service to this report. Vsunip Inspection is reauHrd record results in item 6, below. UST SYSTEM INSPECTION 6 Tank -top containment sumps are fire of water, debris, and hazardous substance. Sensors are located properly. Note: Visual Inspections ofsumps is only required in sumps where an alarm has occurred in the past month for which there is no service record. Y N Y N Sump Location: Sump Location: Sump Location: Sump Location: &Np Location: Sump Location: 7 Spill containment structures are free of water debris and hazardous substance. Y I N INAI Y N NA Tank 1 - Contents: diesel j Tank 3 - Contents: Tank 2 - Contents: I Tank 4 -Contents: 8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located ro PEIY. Y N NA Y N NA Dispenser I / 2 nser 9 / 10 Dispenser 3 / 4 Dispenser 11 / 12 Dispenser S / 6 Dispenser 13 / 14 Dis er 718 Dis enser 15 / 16 ONE PAPERWORK INSPECTION Y N NA DATE D4 Monitoring system certification has been completed within past 12 months. ✓ 9-11-14 10 Secondary containment tests have been completed within the required timeframe. ✓ 9-12-13 11 Spill containment structure(bucket) testing was completed within the past year. ✓ 9-11-14 12 Tank tightness testing was completed within required timeframe. ✓ 13 Line tightness testing was completed within required timeframe. ✓ 14 Other required testis maintenance was completed within required timeframe.(List test/maintenance items below. Test/Maintenance: Test/Maintenance: Test/Maintenance: FACILITY EMPLOYEE TRAINING Y N NA 15 All facility employees have received the required on-the-job training within the past year, ✓ 16 All facility employees hired within the past 30 days have received the required on -the -Job training. ✓ is mie: Any answer or ••rr•• anouia De ezpiamea in the comment section on me ronowmg page, ana win require follow-up action. QA/QC APPROVED 6/1/201511:03AMJustin Tre Page 1 of 2 - 9 crij ENVIRONMENTAL HEALTH DEPARTMENT November 2004