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rw DESIGNATED UNDERGROUND STORAGE TANK (UST) OP; MONTHLY VISUAL INSPECTION CHECKLIST 0 2017 Facility Name Quik Stop Market#148 Date RbUM"M Facility Address 205 W. Lockeford Street HEALTH DEPARTMEN City,State,Zip Lodi,CA 95240 Designated Operator Carpenter,Curtis ICC Certification# 8167865-UC Expiration March 20,2015 Signature L Phone (916)825-7857 Item MONITORING PANEL / ALARM HISTORY Y N NA 1 Monitoring system is powered on and in proper operating mode. 0 ❑ ❑ 2 Monitoring system is NOT currently showing any alarms or warnings. 0 ❑ ❑ 3 Alarm history report/log for the previous month is available,and has been reviewed by the Designated UST Operator. 0 ❑ ❑ 3a Is a copy of the alarm history report/log to this form? ❑ ❑ 4 'Each alarm for the previous month has been responded to appropriately. ❑ ❑ 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: L5 alarmed on 10-28-14. Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and properly addressed,the cause of the alarm. Attach documentation verifying appropriate service to this report ff sump inspection is required,record results in item 6,below. UST SYSTEM INSPECTION 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. Note: Visual inspection of sumps is only required in sumps where an alarm has occurred in the past month for which there is no service record. Y N Sump Location. 89 Annular ❑ Sump Location: ❑ ❑ Sump Location: ❑ ❑ 7 Spill Containment Structures are free of water,debris"and hazardous substance. Y N NA Y N NA Tank 1 - Gasoline 87 E ❑ ❑ Tank 3 - Gasoline 91 0 ❑ ❑ Tank 2 - Gasoline 89 0 ❑ ❑ 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located properly. Y N NA Dispenser 1/2 E ❑ ❑ Dispenser 3/4 0 ❑ ❑ PAPERWORK INSPECTION Date Y N NA 9 Monitoring system certification has been completed within the past 12 months. 07/08/14 1 ❑ ❑ 10 Secondary containment tests have been completed within the required timeframe. 10/27/14 ■ ❑ ❑ 11 Spill containment structure(bucket)testing was completed within the past year. 07/08/14 N ❑ ❑ 12 Tank tightness testing was completed within the required timeframe. ❑ ❑ 0 13 Line tightness testing was completed within the required timeframe. ❑ ❑ E 14 Other required testing/maintenance was completed within the required timeframe. (List items below) Test/Maintenance Air Quality Test 06/23/14 ■ ❑ ❑ 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. ❑ ❑ 02014 w" Page 1 Checklist Pi E---