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Designated Underground Storage Tank (UST) Operatorj� <br />Monthly Visual Inspection Checklist <br />Facili!y Name: Waterloo Shell Date:- <br />Faciliq Address: 4315 Waterloo -- ---- - 1 <br />Cin: Stockton Zip Code: <br />Desi_Rnated UST O �rator Conducting the Inspection.- Lori Freshour THE, <br />International Code Council Certification 4: 522 b <br />Q.ii3 - UC I Ex iration Date: 0/17/(17 `RVQ <br />Ci <br />Suture: i Phone (916)826-1576 <br />.vwivr10KING PANEL ALARM HISTORY Y V <br />f \foniturint,'+stent i. Jim -ed on and in ,rn NA <br />er o erdmk mode <br />i Z � \lonitorink tivaem is nut currently sho,+m• am alarnts ur++arnin •s <br />3 larrn hi.ton report log for the previous month is available- and has been reviewcd hythe Designated l'Sf Operanx. <br />tluch r ,>pr• a/'tht rinrnt hr,ton• rrrorr '- q to this form r1 ,n arinhle) i <br />l Each alarm for the re+ious month has hcenlras ondcd to a ro riateh. i <br />5 Settsun located in the tank -top containment sumps ha+e not alarmed in the Past 111011th5a L isr ail tank.rop rtratpsit here , ilarnrs' uccuri-c l ,n the rsr "I -11 ��++ �� <br />S7,mps where an al7rnt has eh" urred nr the n,zst errnnrly nnrsr he ; n.N'119ri'`i rtnkcs a ; ualr„, sen ;a• !<< <br />pin1 f hnrcran re<p:wdcd rn, ino? <br />prrh nrl;lre,> ;1, rite caro' ni'rhe olrrrnr.. ;na�h d ,c <br />11, On rrrrli rr+t ',pprnprr,ne ,ovrr::r to rhrs rep J.r. <br />.l run 1-0rar,:e% rVe•rird r•e•,uil., ,n rre'rn 6, he•!on•. i <br />UST SYSTEM INSPECTION —, <br />�!6T_Tanl-lop containment sumps are free of water, debris, and hazardous substance. Sensors are properly located. <br />Note Visual rrsoechon of sums is only required in sums where an alarm has oct:urred ,n the ast month for which there is no ,ervice record <br />Sump Location: '7 <br />Sum Location.' <br />Sump Location: <br />7 Spill containment structures are free of water. <br />Tank 1 - Contents , a <br />Tank 2 -Contents 1 <br />8 UDC areas are free of water <br />1/2 <br />3/4 <br />5/6 <br />7/8 <br />Location: <br />Location: <br />Location: <br />and hazardous substance. <br />1 Y N NA <br />Tank 3 -Contents <br />Tank 4 -Contents <br />and hazardous substance. Sensors are properly located. <br />Y N NA <br />PAPERWORK INSPECTION <br />Wc n system certification has been con eted within the spat 12 months. <br />Secondary Containment tests have been completed within the required timeframe. <br />tainment structure (bucket) testing was completed within the past year. <br />htness testin was con leted withinr uired timeframe. <br />tness testing was completed with required timeframe. <br />ierrequired testing maintenance was completed within required timeframe (List <br />_ a Test/ Maintenance. <br />----- <br />-_ Test/Maintenance: — --- — <br />9/10 <br />11/12 <br />12113 <br />14115 <br />Y <br />test/ maintenance items <br />LLD I V <br />in <br />NA <br />NA <br />NA <br />N I NA TDATE DONE <br />_ FACILITY EMPLOYEE TRAINING <br />r 5 A.II facili -- r -- Y N ! NA <br />� ty mployees have received ehe required on-the-job training within the past year. - - -- <br />16 All facilityemployees hired within the past 30 day have received the required on-the-job training -~ <br />_ _ - -- - - - - - - - --- <br />Note: Any answer of "N” should be explained in the comment section on the following page, and will require follow-up action. — <br />Comments: L.. t S" $ l t_�w o -- M o a_n�QQ- L, %� I <br />l`7 T71SP 1/Q /)�nt.t7a� oan4,o1w Q <br />Follow-up action required: <br />Dealer / Manager Signature: <br />Date: <br />