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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: 7-11 19976 Date: 1/19/2016 <br /> Facility Address: 1399 N.MAIN ST. <br /> City:MANTECA Zip Code: 95336 <br /> Designated U Oper o Conduc g the Inspection: Laura Gomez <br /> Intprtratio,naodc C ci 'ert' tion#: 8344748 Expiration Date: 4/14/2017 <br /> gnature: Phone: (949)460-5200 <br /> Y=Yes,N=No,NA=Not AppBeable <br /> mj M . T ORTNG PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring System is powered 96 ato in proper operating mode X <br /> 2 Monitoring system is not curre fly owing any alarms or warnings. X <br /> 3 Alarm history report/log for th revious month is available,and has been reviewed by the Designated UST X <br /> Operator. (Attach a copy of the alarm histoy report log to this form if available.) <br /> 4 Each alarm for the previous month has been responded to appropriately. X <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> 5a - List all tank-top sumps where alarms occurred in the past month: <br /> LA:Premium STP Sump;L5:RUL Fill Sump;L6:Prem Fill Sump <br /> ,Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to,and properly <br /> addressed,the cause ofthe alarm. 4twh documentation verifying appropriate service to this report.Ifsump inspection is required,record results <br /> in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Sum:Usual inspection of sumps is only rcgwred vi sumps where un alarm has on-urred in the past month for which there ism service record. <br /> Y N i;t Y N <br /> Sump Location: ILEA e � Sump Location: WA <br /> Sump Location: NAH Sump Location: NiA <br /> Sump Location: N'^ Sump Location: "'^ <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank-87 X <br /> Tank-91 X <br /> 8 Under-dispenser containment areas are free of water, debris,and hazardous substance. Sensors are located properly. <br /> Y N I NA OCT 14 ZU1b Y N NA <br /> Dispenser-112 X <br /> Dispenser-3/4 X <br /> ENVIKU <br /> DEpARTMENT <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 1 Monitoring system certification has been completed within past 12 months. X 1017/15 <br /> 10 Secondary containment tests have been completed within the required timeframe. X 12118/15 <br /> 11 Spill containment structure(bucket)testing was completed within the past year. X 10/7/15 <br /> 12 Tank tightness testing was completed within required timeframe. X N/A <br /> 13 Line tightness testing was completed within required timeframe. X N/A <br /> 14 Other required testing/maintenance was completed within required timeframe.(List test/maintenance items below) <br /> TestlMaintenance: X N/A <br /> Test/Maintenance: X NIA <br /> Test/Maintenance: X NIA <br /> MIMM <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility employees have received the required on-the-job training within the past year. X <br /> 16 All facility employees hired within the past 30 days have received the required on-the-job I I X <br /> Note: Any answer of"N"should be explained in the comment section an the Mowing page,and will require follow-up <br /> action. <br /> Page 1 of 2 <br />