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f� M4 <br /> Designated Underground (torage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Name: H&M Date : 08/08/ 18 <br /> Facili Address: 2501 E. Jackson Ave Zi Code: 95320 <br /> Ci : Escalon <br /> Designated UST Q erator Conductin the Inspection: Karen R Amain Ex iration Date: 03/30/ 19 <br /> Internationa o Council Ce ification #: 8356759 <br /> Signaturg. h n Phone: { 209 ) 518-4836 <br /> Y = Yes, N =14o. NA = Not Anglicable <br /> Item MONIT G PANEL I ALARM HISTORY Y N NA <br /> 1 Monitoring s stem is powered on and in ro er o erating mode. OWN <br /> =available.2 Monitorin s stem is not currently showin an alarms or warnin s.3 Alarm history report/log for the previous month is available, and has been reviewed byDesi aced UST 0 erator. (Attach a co o the alarm histo re ort/lo to this orm i4 Each alarm for the revious month has been res ondedtoa ro11 1111 riatel . IIIliiiiiiii <br /> 5 Sensors located in tank to containment sumps have not alarmed in the pas month <br /> 5a List all tank-top sumps where alarms occurred in the past month 07/31 due to testing. <br /> Note: Sumps where an alarm has occurred in the past month must he Inspected unless a gualif:ed service technician responded to, and <br /> F properly addressed the cause of the alarm. Attach documentation vertfying appropriate service to this report. <br /> I sum ins ect(on is required 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 ins ectton sum s is on re uiresumps in s where an alarm has occurred in the st month or which there Is no�stervi record. <br /> Y N <br /> Sum .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. Y N NA <br /> Y N NANow <br /> Tank 1 — Contents: 87 X Tank 3 — Contents: Diesel X <br /> Tank 2 -- Contents: 91. X <br /> 8 Under-di enser containment areas are free of water, debris, and hazardous substance. Sensors are located rN er1It <br /> NA <br /> Y N NA <br /> Dis enser 1 / 2 X <br /> Dis enser 3 / 4 X <br /> III liiiii 11 HE III <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitorin system certification has been completed within past 12 months. X 07/31 /17 <br /> 10 Secondary containment tests have been completed within there aired timeframe. X 08/30/ 17 <br /> 11 Spill containment structure (bucket) tesft was completed within the ast ear. X 07/31 / I8 <br /> 12 Tank ti htness testing was completed withha re uired timeframe. Will <br /> 13 Line tightness testing was completed within re uired timeframe. <br /> 14 Other required testing/Maintenance was completed within required timeframe. (List testlmaintenance items below.) <br /> Test/Maintenance: <br /> TestlMaintenance: <br /> Test/Maintenance: <br /> III FA11 CILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facilityemployees have received the required on-the= ob trainin within the ast ear. 05/17/ 18 X X <br /> 16 All facili em to ees hired within the past 30 da have received the r uired on the ' ob training <br /> Note: Any answer of 'IN" 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 />