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C <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: Chevron # 208117 <br />Date: 11/15/13 <br />Facility Address: 755 South Tracy Blvd. <br />Monitoring system is powered on and in proper operating mode. <br />City: Tracy <br />Zip Code: 95376 <br />Designated UST Operator Conducting the Inspection: <br />EDWARD DAHLGREN <br />International C de Council Certification # 8164364 <br />X <br />Expiration Date: 06/28/14 <br />Signature: <br />3 <br />Phone: (209) 601-8163 <br />o / - Y = Yes, N = No, NA = Not Applicable <br />Item MONITORING PANEL / ALARM HISTORY Y I N NA <br />1 <br />Monitoring system is powered on and in proper operating mode. <br />X <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />X <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. (Attach a copy of the alarm history report/log to thisform if available) <br />X <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />X <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />X <br />5a <br />List all tank -top sumps where alarms occurred in the past month: SEE COMMENTS <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 verging appropriate service to this report. <br />If sump inspection is required, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection of sums is only re uired in sumps where an alarm has occurred in the past month for which there is no service record <br />Y I N I NA YJ N NA <br />Sump Location: 87 X Sump Location: 91 X <br />Sump Location: 87 X Sump Location: Diesel X <br />Sump Location: 89 X Sump Location: Vent pie X <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA Y N NA <br />Tank 1 — Contents: 87: Gasoline X Tank 4 — Contents: 91: Gasoline X <br />Tank 2 — Contents: 87: Gasoline X Tank 5 — Contents: Diesel X <br />Tank 3 — Contents: 89: Gasoline X Tank 6 — Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA Y N NA <br />Dispenser: 1/2 X Dispenser: 11/12 X <br />Dispenser: 3/4 X Dispenser: 13/14 X <br />Dispenser: 5/6 X Dispenser: 15/16 X <br />Dispenser: 7/8 X Dis enser: 17/18 X <br />Dispenser: 9/10 X Dispenser: 19/20 X <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. X 2/27/13 <br />10 Secondary containment tests have been completed within the required timeframe. X 3/16/13 <br />11 Spill containment structure (bucket) testing was completed within the past year. X 2/27/13 <br />12 Tank tightness testing was completed 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 />15 Test/Maintenance: LLD X 2/27/13 <br />16 Test/Maintenance: <br />17 Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />18 All facility employees have received the required on-the-job training within the past year. X <br />19 All facility employees hired within the past 30 days have received the required on -the job training. X <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require follow-up action. <br />Page 1 of 2 September, 2012 <br />