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Designated Undergro d Storage Tank (UST <br /> )Operator <br /> Monthly Visual Inspection Chec <br /> Date <br /> Facili Name: H&M <br /> : 09/11/ 18 <br /> Facili Address: 2501 E. Jackson Ave11 WIN <br /> q Code: 95320 <br /> Ci 111111,1111114 <br /> : Escalon <br /> Desi ted UST erator conducting the inspection Karen R Arnaiz Eiration Date: 03 (30/19 <br /> bternati , de Council C 'fication #: 8356759 phone: ( 209 } 518-4836 <br /> Si tore: No, NA = Not A ticable <br /> MO RING PANEL / ALARM EftSTORY Y N NA <br /> Item X <br /> I Monitorin s stem 's owered on and in ro er o eratin made. X <br /> 2 Monitorin s stem is not currentl showin an alarms or warciin s. X <br /> 3 Alarm history report/log for the previous month is available, and has been reviewed by the <br /> Desi ated UST One.. Attach a co o the alarm histo re ortllo to this orm i available. X <br />€ 4 Each alarm for the revious month has been res onded to a ro riatel . X <br /> 5 Sensors located in tank-to containment sum shave not alarmed in thEp <br /> e ast month. <br /> 5a List atl tank top sumps where alarms occurred in the past month. <br /> Note.• Sumps where an alarm lou accurred to the past month must be inspected unless a qualified service technician responded to, an <br />" properly addressed the cause of the alarm. Attach documentation verfng appropriate service to this report. <br />[' ins ection is re uired 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 in ection o sum s is on re uired in sumps where an alarm has occurred in the past month or which there is no service record <br /> Y N <br /> um Location: 87 STP X <br /> Sum Location: 91 STP X <br /> Sum Location: Diesel STP X <br /> 7 S ill containment structures are free of water, debris and hazardous substance. N INA <br /> Y N NA <br /> Tank I — Contents: 87 X Tank 3 — Contents: Diesel X <br /> Tank 2 — Contents: 91 X <br /> 8 <br /> Under-dispenser containment areas are free ofwater debris, and hazardous substance. Sensors are IocateYd r� er NAY N NA <br /> Dispenser I 1112 X <br /> Di s enser 314 X <br /> I <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitorina s stem certification has been completed within past 12 months. X 07/31/ 18 <br /> 10 Secondary containment tests have been completed within the required timeframe. X 08/30/ 17 <br /> 11 Spill containment structure bucket testLZ was completed within the past year. X 07/31 / 18 <br /> 12 Tank tightness testin was completed within required timeframe. <br /> 13 Line tightness testima, was completed within required timeframe. <br /> 14 Other required testing/maintenance was completed within re uired timeframe. List testlmaintenance items below. <br /> Test/Maintenance: <br /> TestlMaintenance: <br /> TestlMaintenance: <br /> FACILITY EMPLOYEE TRAINING YJ N I NA <br /> 15 1 All facili em toees have received the required on-thejob trainin within the pastyear. 05/ 17( 18 X <br /> 16 I.All facility em to ees hired within the past 30 days have received the required on-the job train . 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 i of 2 November 2004 <br />