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P s i t r r rage Tank (USAperator cli Monthly Visual inspection Checklist Facile Mame: efo ®ate: �m Facili Atldres AA City: , W A/Y)Z,71 lZip Code: Valley Underground Tank Monitoring Mailing and Remittance Address: Valley Underground Tank Monitoring P.O. Sox 91 Stockton, CA 95201 Designated UST Operator Conducting the Inspection: Internation e Council Ce ifi tion x iration Date: i nature: 41, Phone: ( g� Y=Yes, N=No, NA=Not Applicable Item Monitoring Panel/Alarm Histo!jY N NA Monitoring"-system is powered on ana in proper operatin onitoring system is not current y s owing any a arms or warnin s. arm istory port/log fort the previous-month-is available,and has been reviews by the Designated UST Operator. (Attach a copy of the alarm history repor0og if available). -77 ach a arm or t e previous mont as been respon e o approprlate y. Sensors oca a in tan -top containment sumps have not alarmed in the past mont . a ist a tan -top sumps where alarms occurre rn t e past moat 1 Note:Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this reportif sump inspection is required,record results in item 6,below. T System Inspection Tank-top containment sumps are ree o water, ens,an azar ous substance. Sensors are located properly. NoteMsual inspection of sumps are only required m n sumps where an alarm has occurred in the past month for which there is no service record ump ocatior flUuocation:ump ocation: ocateon:ocateon: ocateon: pi containment structures are free of water, debris,and hazardous substance. Tank - ontents: _ an - ontents: an - ontents: an - ontents: Hit 1-11 Under--dispenser containment areas are ree o water, debris,an azar ous substance. Sensors are located properly. espenser1/2 ispenser espenser espenser 11712 espenser espenser 13/14 Dispenser espenser Paperwork Inspection `( N NA orntonng system cern,cation as l5een completed within past 12 mont s. icon arycontainment tests have been completed within require timera - Spill containment structure(bucket)testing was compete wit in past year Tank tig mess testing was completed within Te—quired timeframes. 13 Line tightness testing was completed wit in require timeframe. 4er require testing/-maintenance was comp e e wi in require ire rame. (List maint. items below). es maintenance: Test/maintenance: es maintenance: acilit Employee Training Y J N NA 15 All facilityemp oyees have receive t e require on-t a Jo training int a past year. facility-e-m-pTo—yees-hired within the past 30 days have receive t e require on-the-job training. of r of"N"should be explained int the comment section on the folloWfing page, and will require follow-up action. Pg. 1 of 2