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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: 7-1119976 <br />Date: 06/08/2016 <br />Facility Address: 1399 N. NJAIN ST. <br />1 <br />City: MANTEL <br />Zip Codc: 95336 <br />Designated U Op for o ucting a Inspection: Laura Gomez <br />Monitoring system is not currently owing y alarms or warnings. <br />int ationa o one' Certs 4: 8344748 <br />Expiration Date: 4/14/2017 <br />lgnatur . <br />Phone: (949)460-5200 <br />1 1a J Y = Yes, N = No, NA = Not Applicable <br />I m <br />N N PANEL / ALARM HISTORY <br />Y N NA <br />1 <br />Monitoring System is po on 4nd in prop r operating mode <br />X <br />2 <br />Monitoring system is not currently owing y alarms or warnings. <br />X <br />3 <br />Alarm history report/log for the pre0bwwKonth is available, and has been reviewed by the Designated UST <br />Operator. (Attach a copy of the alarm history report/log to this form 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: <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded <br />addressed, the cause of the alarm. iltach documentation verifying appropriate service to this report. IJ'sump inspection is required, <br />in item 6, below. <br />to, and properly <br />record results <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: risua/ inspection u/swops is only required in rumps wherean alarm has mcwred in the past month for which there is no se vw.. record. <br />Y N Vit: <br />Sump Location: WA Sump Location:N'^Sump Location: NiA Sump Location: VASump Location: NM Sump Location: y'" <br />JN�, <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Tank -87 X <br />Tank -91 X <br />IV <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are loqg4 p <br />Y N NA <br />NA <br />Dispenser -112 X <br />Dispenser -3/4 X ENVI RO N M E <br />DEPARTMENT <br />PAPERWORK INSPECTION Y N NA DATE <br />9 <br />Monitoring system certification has been completed within past 12 months. )( <br />78/1115 <br />10 <br />Secondary containment tests have been completed within the required timeframe. X <br />1zMn5 <br />11 <br />Spill containment structure (bucket) testing was completed within the past year. X <br />18/7/15 <br />12 <br />Tank tightness testing was completed within required timeframe. X <br />N/A <br />13 <br />Line tightness testing was completed within required timeframe. X <br />N/A <br />14 <br />Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below) <br />Test/Maintenance: X <br />N/A <br />Test/Maintenance: X <br />N/A <br />Test/Maintenance: X <br />N/A <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />Al] 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 -tip <br />action. <br />Page 1 of 2 <br />J <br />.N <br />