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Shirley Environmental Testing, Corp <br /> Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facilit Name: i i,V Date: <br /> Facility Address: 7 <br /> Cit . i t,c Cade: 52- 01-1 <br /> Desi ed UST Operator Conducting the on: / / <br /> lntemalio CROP,Council Certification# 1-f p / -0 L tion Date: 7 <br /> Si lure. Phone:(y a �� , — 7 c/cJ <br /> YaY N=Ko NA=NotA Irca6tc <br /> Item MONITORING PANEL/ALARM ffiSTORY Y N NA <br /> 1 <br /> Vo onng system is p2Eered on and i <br /> 1p2T2g c9crating mode. <br /> 2 Nlonkorin stem is not cin enll sho: an 7available, <br /> s or warnin . <br /> 3 Alarm-history zepojOog for the previous month iand has been m-newed by the <br /> Desi aced UST O rotor.. Atisxcr q co of them histo re rtlfa to thisform i available. <br /> 4 Each alarm for the revious month has been res d to5 Sensors located in.tank4o containment ' hot alarmed in the past mondr. <br /> 5a - List all tank-top sumps where alarms occurred in the-past)7107th: <br /> Note:Sumps where an alarm has occurred in the past month moat be tnspactsd unless a quaLfeed service AQchnitian r tided ta,and <br /> properly addressed the cause of the alarm.Affaeh documentation i-ir ing appropriate sengce to this report <br /> I sum ins tion is r Iced,record results)ta,itarii 6•heloy�•-� <br /> _. UST SYSTEM INSPECTION - <br /> 6 o N"tV 0=421 in p coodainimeat sumps are free of wafter,debris,and hazardous substance. Sensors are located properly. <br /> Note: tion o sum s is "red tnsu s where an alarm has acraareriin the Past month or which there is no srrvtce record. <br /> Y N Y N7777 <br /> Sum ,Location: Sump Location: <br /> Sump Location, Sump Location: <br /> Sunip Location: Location: <br /> 7 4M containment siructnres ars free of wafer,debris and hazardous substance. <br /> N NA .- <br /> Tank 1—Contents: Tandy 3--Contents: <br /> Tank 2—Contents: Tank 4—Content.- <br /> S Under-dis nser containment areas are free of water,debris,and hazardous substance. Sensors are,10oated ro ed . <br /> Y N �Dimenser <br /> Y N NA <br /> Dts enser}/2 /10 <br /> Dispenser 3/4 Di enser 1 i J 1 <br /> Dispenser 5/6 Dt enser 13114 <br /> Dispenser?/8 Is <br /> user IS/16 <br /> PAFERWORKINSPECTION Y N NA DATE DONE <br /> — <br /> 9 Monito em certification has been completed within past 12 monft O_ o <br /> 10 Seca containment tests have been completed leted within the uired t;merYa e. <br /> 11 Sill containment structure(bucket kstina was completed within the pag year, <br /> 12 Tank ti mess testing was con leted within required timeframe. <br /> 13 Line ti tress testing was completed withinrequired timefiame_ <br /> 14 Other aired testis mainttance was co feted within timeti3u (List lest/maintenance items below) <br /> Tes&Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> p'ACHITY EMPLOYEE TRAINING Y N NA <br /> 15 All facilityern to ees have received the ed on-tho-' tiainin within the v <br /> 16 All fh!rJ ty employees hired within the past 30 days l�avz;received the an-ilio-ob <br /> Note. Any answer of"N"s>aould be explained in the comment section on the following page,and reap require <br /> follow-up action <br /> Shirley Environmental Testing Corporation <br /> 9595 Lucas Ranch Road,Suite#140,Rancho Cucamonga,CA 91730 g. <br /> $00-533-4030 <br />