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Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank (UST) Operator <br /> •. Monthly Visual Inspection Checklist <br /> Facility Name: -c-k k a,t s n . .• Date: o <br /> Facility Address: -3'907 o t-e.Ja LA <br /> City- b I,- .. Zip Code. b <br /> f Desi ed UST Operator Conducting the lnspeclion i(- G+cam `T �-,e <br /> International Code Council Certificaijon# 15Z54-7-3(_-V(- iration Date:Q Z 1 ! -Z as <br /> Si attire: Phone:(`11 6 7 -76 - G� O <br /> Y-Ym N-Fl FIA-Not Applicalik <br /> Item MONITO><tINGPANEI,l ALARM HISTORY Y N NA <br /> '1 Vo system is veered on and in roper operat in node, <br /> 7 monitoring stem is not currently showing any alarms or warnin . <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi aced UST Operator. (Attach a cop o the alarm history repo Oo to thisform i availab <br /> revious month has ble.) <br /> 4 Each alarm for the peen responded to a ro natel . <br /> 5 Sensors located in lank-top containment sumps have not; inure asp month. <br /> 5a List all tank-top sunips where alarms occurred in the pastmonth: <br /> Note:Sumps where an alarm has occurred in the past month must be inspected unless a quahfted service technician responded to,and <br /> Properly addressed,the cause of the alarm.Attach documentabon verifying appropriate service to this report. <br /> 7 sump fns 'on is r aired,record results in item 6.below. <br /> IIS. <br /> T SYSTEM INSPECTION <br /> 6 Tank-top contaiimsent sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note_y1mal inspection o sumsis only rx aired insu a where an alarm hasnccaared in the stmonth ar which there is no service.record <br /> Y N Y dN <br /> Sump Location: w . .,n Suunp Location: <br /> Sum Location: L, v Po Sump Location: <br /> Sump Location: Sump Location: <br /> 7 Spill contaimnent strnctares are free of water,debris,and hazardous substance. <br /> Y N I NA Y N NA <br /> Tank 1-Contents: L t Tank 3-Contents: <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located prope <br /> Y N I NA I Y N NA <br /> .Dispenser 1 J 2 Di eraser 9/10 <br /> Di eraser 3/4 Di eraser 11/12 <br /> Dispenser S/6 Dis eraser 13114 <br /> D4yenser 718 Dis eraser 1 S 116 <br /> PA.PERWORKINSPECTION X N NA DATE DONE <br /> 9 Monitoring gstem certification has been conletcd within st 12 months. Z r <br /> 10 Secondary containment tests have been completed within the required timeframe. <br /> 11 Spill containment structure(bucket testin was completed within the ear. -Z y-� <br /> 12 Tank ii tress testing was completed within required timeframe. iL e o� <br /> 13 Line tightness testing was completed within x aired timeframe. <br /> 14 Other mquired testin maintenance was co leted within required to nefinme. (List iestImaintenanc:e items below.) <br /> Test/Maintenance: <br /> TestlMaintenance: <br /> TesWaintenance_ <br /> FAcu TY EWLOYEE TSG Y N NA <br /> 15 All facility ern loyees have received theaired on-the b training within the past year. <br /> 16 All facility em loyees hired within the past 30 days have received the required on the=ob lraii . <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-rasp action. <br /> Shirley Environmental Testin&Corporation <br /> 9595 Lucas Ranch.Road,suite#loo,Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />