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0 0 <br />Site ID: 1300-1 <br />Afforda-Te$t Designated Operator <br />416 2nd Street g p <br />Galt, Ca 95632 Monthly Inspection Checklist <br />209-744-0112 Fax 209-744-0116 <br />Site: VAN DE POL - LODI PACIFIC PRIDE <br />351 BECKMAN RD <br />LODI, CA 95240 <br />�I� 2 2017 <br />® Zane A. Nimmo ❑ David A. Winkler ❑ Felix G. Ramirez ❑ Edwar'd QW NTAL HEALTH <br />#5263322 #5263373 #5273934 #525049E PARTM ENT <br />Y = yes N = no, NA = not applicable <br />MONITORING PANEL / ALARM HISTORY <br />Y <br />N <br />NA <br />Monitoring system is powered on and in proper operating mode. <br />X <br />Monitoring system is not currently showing any alarms or warnings. <br />X <br />Alarm history report/log for the previous month is available, and has been reviewed by the Designated UST <br />Operator. Attach a copy of the alarm history report/logreport/log to thisform i available. <br />X <br />Each alarm for the previous month has been responded to appropriately <br />X <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />X <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 properly <br />addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. If sump inspection is required, record results <br />in item 6, below. <br />UST SYSTEM INSPECTION <br />Y I N FNA I <br />Y I N NA <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection o sum s is only required in sum s where an alarm has occurred in the past month or which there is no service record. <br />Sump Location: 87 STP SUMP X <br />Sump Location:91 STP SUMP X <br />Sump Location: DIESEL X <br />Sump Location: RED X <br />Sump Location: DIESEL STP X <br />S ill containment structures are free of water, debris, & hazardous substance. <br />Tank 1 - Regular X Tank 5 -RED DIESEL <br />X <br />Tank 2 — Plus X Tank 6 -DIESEL 2 <br />X <br />Tank 3 - Premium X Tank 7 - <br />Tank 4 —Diesel 1 X Tank 8 - <br />Under -dispenser containment free of water, debris, & hazardous substance. Sensors located properly. <br />Dispenser 1/2 X Dispenser 19/20 <br />X <br />Dispenser 3/4 X Dispenser 21 <br />X <br />Dispenser 5/6 X Dispenser 22/21 <br />X <br />Dispenser 7/8 X Dispenser 23/22 <br />X <br />Dispenser 9/10 X Dispenser 24/23 <br />X <br />Dispenser 11/12 X Dispenser 25/24 <br />X <br />Dispenser 13/14 X Dispenser 26/25 <br />X <br />Dispenser 15/16 X Dispenser 27/26 Satellite <br />X <br />Dispenser 17/18 X Dispenser 27 <br />X <br />