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0 <br /> Designated Underground Storage Tank (UST) Opel _ f "" ti <br /> Monthly Visual Inspection Checklist ' s m <br /> Facility Name:French Camp Date: 12 V1 --1 <br /> Fa <br /> cilit Address: 10842 S.Harlan Rd. - <br /> Cit : French Camp Zi Code: 95231 <br /> Desi nated UST O for Conducting the Inspection: Steven Richardsong �,� woes __ a L J <br /> International uncil Certification#:8218604 Ex iration Date: 8 <br /> Signature: Phone: 916 825-7412 <br /> Y=Yes N=No NA=Not A licable <br /> Item MONITORING PANEL/ALARM HISTORY Y I N NA <br /> 1 Monitorin s stem is owered on and in proper operating mode. X <br /> 2 Monitoring system is not currently showing any alarms or warnings. X <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the X <br /> Designated UST Operator. Attach a ceeKof the alarm history reportllog to thisform if available. <br /> 4 Each alarm for the previous month has been responded to appropriately. X <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. X <br /> 5a _ 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 aired,record results in item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Visual inspection o sums is only re uired in sum s where an alarm has occurred in the past month for which there is no service record. <br /> Y N Y N ' <br /> Sump Location: Sump Location: <br /> Sump Location: Sum Location: <br /> Sump Location: um <br /> Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y I N NA I Y N NA <br /> Tank 1—Contents:DFC Ix 1Tank 3—Contents: <br /> Tank 2—Contents: I Tank 4—Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located ro erl . <br /> Y N NAY N NA <br /> Dispenser la <br /> X Dis enser 5 X <br /> Dispenser 1/2 X Dis enser <br /> Dispenser 314 X Dis enser <br /> Dis enser 4a/5a X Dis enser <br /> Ifflimmms .2 <br /> o <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitoring s stem certification has been completed within past 12 months. X 10-30-14 <br /> 10 Secondar containment tests have been completed within the required timeframe. X 12-17-14 <br /> 11 S III containment structure bucket testingwas completed within the past year. X 10-30 iL <br /> 12 Tank ti htness testin was com leted within required timeframe. X <br /> 13 Line ti tness testin was com leted within re uired timeframe. X <br /> 14 Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facilit employees have received the required on-the-'ob traiig within the ast ear. X <br /> 16 All facilit em to ees hired within the ast 30 da s have received the required on-the-job trainin . 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 />