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DESIGNATED UNDERGROUND STORAGE TANK (UST) OPERATOR <br />MONTHLY - • <br />Facility Name <br />New West # 1003 <br />Date September 17, 2009 <br />Facility Address <br />6437 W. Banner Road <br />2 <br />City, State, Zip <br />Lodi, CA 95242 <br />❑ <br />Designated Operator <br />Fast, Alex <br />Alarm history report / log for the previous month is available, and has been reviewed by the Designated UST Operator. <br />ICC Certification # <br />5307848 -UC <br />Expiration March 24, 2009 <br />3a <br />�� <br />0 <br />Signature <br />❑ <br />Phone (916) 869-0023 <br />Item <br />1 <br />_ MONITORING PANEL / ALARM HISTORY <br />Monitoring system is powered on and in proper operating mode. <br />Y <br />� <br />N <br />❑ <br />NA <br />❑ *' <br />2 <br />Monitoring system is NOT currently showing any alarms or warnings. <br />0 <br />❑ <br />❑ <br />3 <br />Alarm history report / log for the previous month is available, and has been reviewed by the Designated UST Operator. <br />N <br />❑ <br />❑ <br />3a <br />Is a copy of the alarm history report/ log to this form? <br />0 <br />❑ <br />❑ <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />❑ <br />❑ <br />❑ <br />5 <br />Sensors located in tank -top containment sumps have NOT alarmed in the past month. <br />❑ <br />0 <br />❑ <br />5a <br />List all tank -top sumps where alarms occurred in the past month: <br />Y N <br />NA <br />Y <br />N <br />NA <br />Gasoline - 87 0 ❑ <br />❑ Diesel <br />1 <br />0 <br />❑ <br />❑ <br />Gasoline - 91 0 ❑ <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 addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />If Sump ction is required, record results in item 6, below. <br />❑ <br />❑ <br />❑ <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous <br />substance. Sensors are located properly. <br />Note: Visual inspection of sumps is only required in sumps where an alarm <br />has occurred in the past month for which there is no service record. <br />Y N <br />Y <br />N <br />Sump Location: ❑ ❑ <br />Sump Location: <br />❑ <br />❑ <br />Sump Location: ❑ ❑ <br />Sump Location: <br />❑ <br />❑ <br />7 Spill Containment Structures are free of water, debris, and hazardous <br />substance. <br />Y N <br />NA <br />Y <br />N <br />NA <br />Gasoline - 87 0 ❑ <br />❑ Diesel <br />1 <br />0 <br />❑ <br />❑ <br />Gasoline - 91 0 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 Under -dispenser containment areas are free of water, debris, and <br />hazardous substance. Sensors are located properly. <br />Y N <br />NA <br />Y <br />N <br />NA <br />Dispenser 1 / 2 ❑ <br />❑ Dispenser 11 / 12 <br />0 <br />❑ <br />❑ <br />Dispenser 3 / 4 ❑ <br />❑ Dispenser 13 / 14 <br />❑ <br />❑ <br />Dispenser 5 / 6 ❑ <br />❑ Dispenser 15116 <br />❑ <br />❑ <br />Dispenser 7/8 N ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser 9 / 10 0 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />©2007 WE:�— Page 1 Checklist P1 <br />