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AUG/17/2021/TUE 02,23 PM Tracy Truck Stop FAX No,209832 2312
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<br />Has each follow-up action of Seotlon III from the previous inspection been completed appropriately?
<br />Attach documentation verllylpg appronrlate service to this report_
<br />Attach a copy of the alarm hlslary report/log to this report
<br />Is the monitoring system powered on and in proper operating modes
<br />Has each leak detection alarm since the previous inspection been responded to appropriately_?
<br />Attach documentation verifying appropriate service to this report.
<br />Have all containment sumps that have had a leak detection alarm since th
<br />ualified UST Service Technician? e previous inspection been responded to by a El ElIR
<br />List below in Section IX all containment Sumps that have had a leak detection alarm since the previous Inspection and have not been
<br />responded to by a qualified UST Service Technician_ Contaimnenf sumpb listed below require a visual Inspection for damage, water, dabrls,
<br />hazardous substance and ro er sensor location. The results of the visual Inspection must ba recorded in Section IX.
<br />Is the containment sump free of dame e, water, debris, and hazardous substance?
<br />Containment Sum ID
<br />To0
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<br />❑❑
<br />Are all sensors in containment sumps Inspected located to detect a leak at the earliest opportunity?
<br />Is the spill container free of damage, water, debris, and hazardous substance?
<br />Tank JID 187 ❑ Tank ID JDSL
<br />Tank ID 191 1Ell [] Tank ID
<br />Is the fill i i
<br />of obstructions?
<br />Tank ID s7
<br />Tank ID 91
<br />Is the fill ca sect
<br />Tank ID s�
<br />Tank ID 191
<br />Is the underiedlap�
<br />Under-Dis
<br />Dispenser 112
<br />Are all sensors in
<br />containment free
<br />er Containment ID
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<br />❑
<br />TanklD
<br />DSL
<br />❑
<br />I Tank ID
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<br />© d TanklD
<br />wat��eyIr, debris, and hazardous substa
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<br />rte, mIrldliII
<br />til Under-Dis enE
<br />D ❑ ❑ Dispenser 3/4
<br />L7 ❑ ❑ Dispenser 7/8
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<br />"M VE
<br />containment locat®d to detect a leak at the earliest
<br />3?
<br />Containment ID
<br />Was the monitoring system celtlflcation been completed within the past 12 months?
<br />Has the spill container testing been completed within the past 12 months?
<br />Has the overfill prevention equipment Inspection been completed within the past 36 months?
<br />Has the secondary containment testingbeen completed within the past 36 months?
<br />Has the tank tightness testing been completed within required timeframes?
<br />Has the line tightness testing been completed within the. required timeframes?
<br />Other required testing / maintenance was completed within required timeframe. (List test/malntenance items
<br />Test /Malnten
<br />Test/ Mainten
<br />Test / Malnten
<br />Test 1 Mainten
<br />Test / Maintan
<br />Test/ Mainten
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<br />Have all individuals perrorming facility employee dutiEs received the required facility employee training within the past 12 months?
<br />l the facility has more components than this form accommodates, additional copies of this page maybe attached.
<br />Y=YWIN = No, NA=Not Aoolirable-115 = IdentfiraHnn
<br />Received Time Aug, 11' 2021 3:19PM No. 6863
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<br />Have all individuals perrorming facility employee dutiEs received the required facility employee training within the past 12 months?
<br />l the facility has more components than this form accommodates, additional copies of this page maybe attached.
<br />Y=YWIN = No, NA=Not Aoolirable-115 = IdentfiraHnn
<br />Received Time Aug, 11' 2021 3:19PM No. 6863
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<br />Have all individuals perrorming facility employee dutiEs received the required facility employee training within the past 12 months?
<br />l the facility has more components than this form accommodates, additional copies of this page maybe attached.
<br />Y=YWIN = No, NA=Not Aoolirable-115 = IdentfiraHnn
<br />Received Time Aug, 11' 2021 3:19PM No. 6863
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<br />Have all individuals perrorming facility employee dutiEs received the required facility employee training within the past 12 months?
<br />l the facility has more components than this form accommodates, additional copies of this page maybe attached.
<br />Y=YWIN = No, NA=Not Aoolirable-115 = IdentfiraHnn
<br />Received Time Aug, 11' 2021 3:19PM No. 6863
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<br />Have all individuals perrorming facility employee dutiEs received the required facility employee training within the past 12 months?
<br />l the facility has more components than this form accommodates, additional copies of this page maybe attached.
<br />Y=YWIN = No, NA=Not Aoolirable-115 = IdentfiraHnn
<br />Received Time Aug, 11' 2021 3:19PM No. 6863
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