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Designated Underground Storage Tank(UST)Operator <br /> _ Monthly Visual Inspection Checklist <br /> ! Facility Name: 99 Shell Date: <br /> i Facility Address: 7700 Moreland Ct <br /> City: Stockton I Zip Code: <br /> j Designated UST Operator ConducWig the Inspection.- Lori Freshour <br /> LInternational Code Council Certification#: 5220353 -UC ! Expiration Date: -911-7W y ,'t i. ., <br /> ! Signature: j Plione: 1916;-26-1-57li <br /> Item MONITORING P&NU- . ALARM HISTORY Y • N NA <br /> I \lonitorin>system is po%%cred on and in properoperating mode <br /> i 2 1 )lonitoring system is not curtently showing any alamis or«arnings <br /> 3 Alarm histon report log for the prexinuc month is available,and has been reviewed by the Designated t ST Operator. <br /> 01rach a co Y ofthe alarm histo?•report '1q-,to this form ifamlahle) <br /> 4 Each alarm for the rcvious nwnth has been responded to appropriately. <br /> �! <br /> 5 I Scnsors located in the tank-top contauiment sumps have not alanned in the past month ,',i <br /> 5a List all tank-top smmpc where alarms occurred in the past month: <br /> .N'ote:Rumps inhere an alarm has occurred in the past month must he insnecr.d unless a qualified service technician reslxtndcd ta.and <br /> properly addressed•the cause of the alartrt. Attach documentation it,riA,ing appropriate.sen.tcc to this report. <br /> If snintimspection is recurred.record results in item 1,below. <br /> j UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are properly located. <br /> Note Visual inspection of sums is only required in sumps where an alarm has occwed in the ast month,`or which'here is no service record <br /> Y N Y N <br /> Sump Location: i UMP Location: ! <br /> Sump Location: Sump Location: <br /> Sump Location: Sump Location: <br /> 7 S ill containment structures are free of water, debris,and hazardous substance. <br /> Y N I NA Y N I NA <br /> Tank 1 -Contents r ! Tank 3-Contents ; <br /> Tank 2-Contents , t 4— Tank 4-Contents p. ; <br /> 8 UDC areas are free of water,debris,and hazardous substance. Sensors are properly located. <br /> Y N NA ! Y N I NA <br /> Dispenser 1/2 Dispenser 9/10 <br /> Dis enser 3/4 I Dispenser 11/12 Iv 1 <br /> Dispenser 5/6 Dispenser 12/13 l r <br /> Dispenser 7/8 i Dispenser 14/15 ! <br /> PAPERWORK INSPECTION Y I N NA DATE DONE <br /> 9 Monitoring system certification has been completed within the past 12 months. <br /> 10 Secondary Containment tests have been completed within the required timeframe. <br /> 11 Spill containment structure(bucket)testing was completed within the past year. <br /> 12 Tank ti htness testing was completed within required timeframe. r`, !/ 1 <br /> 13 Line tightness testing was completed with required timeframe. <br /> 14 Other required testing maintenance was completed within required timeframe. (List test/maintenance items below) <br /> Test/Maintenance: <br /> Test/Maintenance: r ;,• i ! <br /> I , I <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility employees have received the required on-the-job training within the past year. <br /> 16All facility' All employees hired within the past 30 day have received the required on-the-job training 1, i <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: <br /> Follow-up action required: <br /> Dealer/Manager Signature: Date: <br />