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7 $ <br /> t N/E D <br /> !1s OF t^I <br /> Designated Underground Storage Tari(UST) Operator <br /> Monthly Visual Inspect' n Checklist ����' 13 Z0117 <br /> Facilit Name: French Cam Date: e) <br /> Facilit Address: 10842 S.Harlan Rd. E.� H E P � .H <br /> Ci :French Cam Zi Code:95231 ''y, ', , <br /> C)FT <br /> Designated US ator Conductingthe Inspection:Steven Richard' n <br /> Internationa Council Certification#:8218604 iration Date: 8 /,,,29 /17 <br /> Si nature: Pho°e: 916 .�_._ $25-7412 <br /> Y=Yes N=No NA=Not A licable <br /> I <br /> MONITORING PANEL/ALARM HISTORY Y N NA <br /> nitorin s stem is owered on and in ro er o eratin mode. " <br /> X <br /> nitorin s stem is not currentlyshowingan alarms or warnings. X <br /> rm history report/log for the previous month is available,and has been reviewed by the X <br /> i nated UST O erator. Attach a co o the alarm histo report/lo to this form i available. <br /> h alarm for the revious month has been responded to appropriately. X <br /> ors located in tank-to containment sumps have not alarmed in the past month. }{ <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 to,and <br /> properly addressed the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> I sum ins ection is re uired,record results in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 KTank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Visual ins ection o sum s is,1111 re uired in sum s where an alarm has occurred in the ast month or which there is no service record. <br /> Y NYN <br /> ocation: Sum Location:ocation: Sum Location: ss <br /> Sump Location: Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1—Contents:DFC X Tank 3—Contents: <br /> Tank 2—Contents: Tank 4—Contents: <br /> 8 Under-dis enser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N NA Y N NA <br /> Dis enser la X Dis enser 5 X <br /> Dis enser 1/2 X Dis enser <br /> Dis enser 3/4 X Dis enser <br /> Dis enser 4a/5a X Dis enser <br /> PAPERWORK INSPECTION N <br /> 9 Monitoring s stem certification has been completed within past 12 months. X N NA DATE DONE <br /> 10 Secondar containment tests have been completed within the required timeframe. X 10-30-14 <br /> 11 S ill containment structure bucket testin was completed within the past year. X 12-17-14 <br /> 12 Tank tightness-tpqtincywas com leted within required timeframe. _. 10-30-1tj ic( <br /> 13 Line ti htness testingwas completed within required timeframe. X <br /> 14 Other required tin maintenance was completed within required timeframe. (List test/maintenance items below.) <br /> Teest/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING �X <br /> 15 All facilityemployees have received the required on-the job trainingwithin the past year. X N NA <br /> 16 All facility em to ees hired within theast 30 da s have received the re uired on-the- training. X <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Page 1 of 2 November 2004 <br />