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0 0 <br />W/O#: 121023-54 1 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: Mid City Ca FO Re en <br />Date: 12/07/12 <br />Facility Address: 13850 Devries Road <br />City: Lodi <br />Zi Cade: 95242 <br />Designated UST Operator Conducting the inspection: Ruben Becerra <br />Intematio 5307833 -UC <br />Signature: <br />Expiration Date: 04/05/13 <br />Phone: (909) 594-9850 <br />+u v i +vv i4 vv.wu, iv I =" ICS, t\ � 1\U, 1\K � 1\Ut Krtrlll4tlUl <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 wam ings, ✓ <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 been responded 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 qualified service technician responded to, and <br />properly addresses, the cause of the alarm. Attach documentation verifying appropriate .service to this report. <br />Ifsump inspection is re uirett record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are ftee of water, debris, and hazardous substance. Sensors are located properly. <br />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. <br />Y N Y N <br />Sump Location: trans box ✓ Sump Location: <br />Sump .Location: vent box ✓ Sump Location: <br />Sum Location: Sump Location: <br />7 Spill containment structures are free of water,debris and hazardous substance. <br />Y N NA Y N NA <br />Tank 1 - Contents: Diesel ✓ Tank 3 - Contents: <br />Tank 2 _-C4 ntents: Tank 4 - Contents: <br />8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located ro erl Y. <br />Y N NA Y N I NA <br />Dispenser I / 2 Dispenser 9 / 10 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser S / 6 Dispenser 13 / 14 <br />Dispenser 7 / 8 Dispenser 15 / 16 <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. ✓ 09/11112 <br />10 Secondary containment tests have been completed within the required timefiame. ✓ 09/13110 <br />I1. Spill containment structure bucket testingwas completed leted within the past ear. ✓ 09/11/12 <br />12 Tank tightness tastin was com feted within required timeframe. ✓ <br />13 Line tightness testing was completed within required timeframe. ✓ <br />14 Other required testin maintenance was completed within required timeframe.(List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y I N NA <br />15 All facility employees have received the required on-the-job training within the past year. ✓ <br />16 All facility employees hired within the past 30 days have received the required on -the -Job training. ✓ <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Page i of 2 November 2004 <br />