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Designated Unde#ound PW <br /> Storage <br /> Monthlyi Inspection li t <br /> Facility Name: Date: <br /> Facility Address: <br /> Ci : .�- i —Code: <br /> -/ ,, Valley UndergroundTank Monitoring <br /> Mailing and Remittance Address: Valley Underground Tank Monitoring <br /> P.O. Box 91 <br /> Stockton, CA 95201 <br /> Designated LIST Operator Conduct in the tns action: <br /> International Code Council Certification Expiration Date: <br /> Signature: Phone: <br /> Y=Yes,N=No, NA=Not Applicable <br /> Item Monitoring Panel/Alarm History Y N NA <br /> Monitoring system is powers on an m'proper operatin mo e. <br /> onitoring system Is not current y Showing any alarms or warnings. <br /> arm istoryrepo Og fort e previous month is available,and has been reviews <br /> by the Designated UST Operator.(Attach a copy of the alarm history reportllog if available). <br /> Each alarm for the previous month as been responue-d o appropriate y. , <br /> nsors oca e in an -top con ainment sumps ave n off a armed in the pastmont . <br /> a list all tan -top sumps w ere a arms occurre in the past mont : <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service <br /> technician responded to, and properly addressed, the cause of the alarm. Attach documentation verifying <br /> appropriate service to this report. If sump inspection is required, record results in item 6,below. <br /> T System Inspection <br /> an -top containment sumps are ree o water, a ris, and hazardous su stance. <br /> Sensors are located properly. NoteMsual inspection of sumps are only required <br /> in sumps where an alarm has occurred in the past month for which there is no service record <br /> ump ocation: ump ocation: <br /> ump ocation: <br /> Sump Location: umpocation: <br /> roussu <br /> stpi containment structures are reewe ;ns, n ance. <br /> Tank -Contents:YJ ITank 3-Contents: <br /> an - ontents: an - ontents: <br /> Under-dispenser containment areas are tree of water, debris, and hazardous substance. Sensors <br /> are located properly. <br /> Dispenser 112 T5—ispenser 9710 <br /> ispenser3/4 ispenser 11712 <br /> ispenserDispense--r 1-3/14 <br /> Dispenser 779 Dispenser <br /> Paperwork Inspection YN NA <br /> onitorin system certification has een complete8 within past mons S. <br /> 75- econ ary containment tests ave een complefe8 wit in required time rame. <br /> pi containment structure(bucket)testing wascomp ate wit in past year. <br /> Tank lightness testing was compete wit in require time rames. <br /> fr Line tightnesstestin was comp ete wit in require time rame. <br /> 14 er required testing/maintenance was comp e e wi in require ime rame. (List mains.items below). <br /> es maintenance: <br /> es maintenance: <br /> es maintenance: <br /> Facility Employee Training Y N NA <br /> aci it amp oyees ave received the require on-t e-job training in the past year. <br /> aci ity emp oyees ire wit in t e past 30 days ave receive t e require <br /> on-the-job training. <br /> Note: Any answer oshould be explained in the comment section on the following page, <br /> and will require follow-up coon. <br /> Pg. 1 of 2 <br />