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Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name:H&M Date:03/06/12 <br /> Facility Address:2501 E.Jackson Ave <br /> City:Escalon Zip Code:95320 <br /> Designated UST Operator Conducting the Inspection:Karen R Arnaiz <br /> International Code Council Certification#: 8032295-UC Expiration Date: 06/11/13 <br /> Signature: Phone: (209) 518-4836 <br /> Y=Yes N=No,NA=Not A liceble <br /> Item MONITORING PANEL/ALARM HISTORY Y I N NA <br /> 1 Monitoring system is powered 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 copy of the alarm history report/logrepor0og to thisform i 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 verging appropriate service to this report. <br /> 1 sum inspection is re aired,record results in item 6,belom <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 stens is only re uired itt sumps where an alarnt has occurred in the past month or which there is no service record <br /> Y N Y N <br /> Sump Location: 87 STP X <br /> Sump Location: 91 STP X <br /> Sump Location:Diesel STP X <br /> 7 Spill containment structures are free of water,debris,and hazardous substance, <br /> Y N NA Y N NA <br /> Tank 1 —Contents:87 X Tank 3-Contents:Diesel X <br /> Tank 2—Contents:91 X <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located properl . <br /> Y N NA Y N NA <br /> Dispenser 1/2 X <br /> Dispenser 3/4 X <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> F11 <br /> Monitorin s stem certification has been com leted within past 12 months, X 07/13/11 <br /> Seconda containment tests have been com leted within the re uired timeframe. X 06/09/11 <br /> S ill containment structure(bucket)testin was com leted within the past ear. X 07/13/11 <br /> Tank tightness testingwas completed within required timeframe. <br /> Line ti htness testing was completed within required timeframe. <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 facili employees have received the required on-the-job training within the past year. 06/20/11 X <br /> Ib 1 All facili employees hired within the past 30 da s have received the required on-the-job 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 />