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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: H&M <br />bate: 05/13/14 <br />Facility Address: 2501 E. Jackson Ave <br />Monitoring system is powered on and in proper operating mode. X <br />City: Escalon <br />Zip Code: 95320 <br />Designated UST Operator Conducting the Inspection: Karen R Arnaiz <br />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 reporillog to thisorin i available./ <br />International Code Council Certification #: 8032295-tJC <br />Expiration Date: 05/31/15 <br />Signature: <br />Phone: (209) 518-4836 <br />Item <br />. 1J11. — INV— is = lNut.%ppl.CSiVic <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />1 <br />Monitoring system is powered on and in proper operating mode. X <br />2 <br />Monitoring system is not currently showing any alarms or warn in s. X <br />3 <br />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 reporillog to thisorin i available./ <br />4 <br />Each alarm for the previous month has been responded to appropriately, X <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. X <br />5a <br />_ List all tank -top sumps where alarms occurred in the past month: L1 & L4 <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br />properl}= addressed, the cause of the alarm. Attach documentation verging appropriate service to this report. <br />1 su ins ction is re uired11 1, record results in item 6, below. <br />x <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection o sums is anty requi in sums where an alarm has occurred in the pastmonthfor which there is no service record. <br />Y N Y N <br />Sump Location: 87 STP X <br />Sump Location: 91 STP X <br />FS—ump Location: Diesel STP X <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA I Y N INA <br />Tank 1 – Contents: 87 X I Tank 3 – Contents: Diesel X <br />Tank 2 – Contents: 91 X <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y I N I NA Y I N INA <br />Dispenser 1/ 2 X <br />Dispenser 3 / 4 X <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 <br />r12 <br />Monitoring system certification has been completed within past 12 months. X 08/08/13 <br />10 <br />Second containment tests have been completed within the required timeframe. X 06/09/11 <br />11 <br />Soil] containment structure bucket) testin was completed within the past year. X 08/08/13 <br />Tank tightness testing was completed within required timeframe. <br />13 1 <br />Line tightness testing was completed within required timeframe. <br />14 <br />Other required testing1maintenance was completed within required timeframe. (List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y I N NA <br />15 <br />All facility employees have received the required on-the-job training within the past year. 06/03/13 X <br />16 <br />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 <br />November 2004 <br />