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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: COSTCO 1031 <br />Date: 912/2015 <br />Facility Address: 2440 Daniels St. <br />City: Manteca <br />Zip Code: 95336 <br />Designated UST Operator Conducting the Inspection: Gabriel Martin <br />Monitoring System is powered an and in proper operating mode <br />International Code Council Certification 4: 8260320 <br />Expiration Date: 615/2016 <br />Signature: <br />Phone: (949) 460-5200 <br />- res, N =No, NA W Not Appuautc <br />Item <br />MONITORING PANEL 1 ALARM HISTORY <br />Y I N <br />NA <br />t <br />Monitoring System is powered an 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 repordlog for the previous month is available, and has been reviewed by the Designated UST <br />Operator. (Attach a copy of the alarm history reportliog to this form if available.) <br />X <br />Ea alarm for the previous month has been responded to appropriately. <br />in <br />X <br />5 <br />Scnsors 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: <br />All Somps <br />Note, Sumps where an alarm has occurred in the past month must he inspected unless a qualijied service technician responded to, and properly <br />addressed, the cause of the alarm: Attach documentation verifying appropriate service to this report. If sump inspection is requireg record results <br />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 />lVole., Vltual inrpecRon ofsumm is unly requirert In sumps whete an alarm has orcurredlrr the past manth far which there ism seroce record. <br />Y N `. <br />Y N <br />Sump LocatiUn: r<rn <br />Sump Location: ""A <br />Jump Location: <br />.Sump Location: WA <br />Sump Location: ntA > <br />Sump Location: NJA <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA ~� <br />Y N <br />NA <br />Tank -87W <br />X Tank -91— <br />X <br />4— <br />Tank-87E <br />X Tank -additive <br />X <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA <br />Y N <br />NA <br />Dispenser -11.2 X Dispenser-9VJO <br />X <br />Dispenser -314 X Dispensei-11/12 <br />X <br />Dispernser-5.16 X Dispenser -13114 <br />X <br />Dispenser -718 XUispenscr-15/16 <br />K <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 <br />Monitoring system certification has been completed within past 12 months. X <br />8/19/1.9 <br />10 <br />Secondary containment tests have been completed within the required timeframe. X <br />IviA <br />11 <br />Spill containment structure (bucket) testing was completed within the past year. X <br />8119/15 <br />12 <br />Tank tightness testing was completed within required timeframe. X <br />11/A <br />13 <br />Line tightness testing was completed within required timeframe. X <br />Nh% <br />14 <br />Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below) <br />Te.stlMaintenance: X <br />VIA <br />TestlMaintenance: X <br />NIA <br />Te.stlMaintenance: X <br />NIA <br />FACILITY EMPLOYEE TRAINING <br />Y N <br />NA <br />15 <br />All facility employees have received the required on-the-job training within the past year. <br />X <br />16 <br />All facility employees hired within the past 30 days have received the required on-the-job training. <br />X <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require follow-up <br />action. <br />Page I of 2 <br />