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Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual inspection Checklist <br /> '". Facilzt Name: [ 7 ('•/a- c�IT C +f Date: <br /> l~acili Address: !� r;-7 I C �� icy A <br /> City-, 5 T C_ KT- Cade: q -)V <br /> Designated UST Operator Cojiq5ltg the n: 77,41-1 ,it.l ✓til 1 <br /> International Coa Cca�cil Certification -Gf Cf2gpiration Date: <br /> Si aLnnC; l'hane: �-/ .3 <br /> Xb'Y N=Na NA—NotA 13cabie <br /> Item MONITORING PANEL I ALARM HISTORY =the <br /> I Monitorin em is ered on and in ro mode.2 Monitorin stem is not dmrntl sho am ahlnwor watnin_3._. ..warm history report/log for the previous mo is available,and has been reviewed Desi ated UST O rotor. 4hthe alarm histo re rt/lo to this ar <br /> 4 Each alarm for the revious month has been nded to ro <br /> 5 Sensors-located in-tank-to ,containruent surra have not alarmed in the mon& <br /> 5a List all tank--top sumps where alarms occurred in the past month: <br /> Note:Suynps where an alarm has ocmund in the past month rust be inspected unless a quahfred service techniclax responded to and <br /> properly addressed,the cause ofths alarm.Affach documentation merit1ng appropriate service to this report <br /> I sum fns flan is required,record results to item b bekiv, <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top comUument sumps are free of water,debris,and baiardous substance. Sensors are located properly. <br /> Note:Ysual in flan o sum s is on red In sr In the g month or which there is <br /> Y no terpfce rPODrd <br /> N - Y N <br /> Sum Location; :Sum Location: - c <br /> Su Lavation: Lavation: <br /> Sum Location. ,� Location: <br /> 7 Spill containment structures are free of water,debris and ha rdous substance. <br /> Y NA Y N NA <br /> 'Tank I—Contents: Tank 3�-Contents <br /> Tank 2 Contents: Tank 4—Contents. <br /> S Under-digs nser containment areas are frce of water,debris,and hazardous substance. Sensors art;located rl . <br /> Y N NA Y N NA <br /> Dispenser 1/2 —Dispenser 9110 <br /> Dispenser 3/4 A Di enser 11/12 <br /> Di eraser 516 Dispenser 13/14 <br /> 8 Di nser 718 Dis r IS/16 <br /> em cer0cation hPAPERWORKINSPECTION Y NA DATE DONE <br /> 9 Monitozin as been completed within past 12 months. <br /> XO Seco containment tests have been co leted within the nuited timeftame. <br /> I 1 S iii containment structure(bucket was co feted withm the past year <br /> 12 Tank ti ess testing was completed witiain r timeframe. <br /> 13 Lice ti tress testis was co leted within vires timeframe. <br /> I4 Oktier r aired testis rnainte[rance was co feted withia timeframe. (List test/maintenatrce items below.) <br /> Te s:Waintenance; <br /> TesWaintenance: <br /> Test/Maintenance: <br /> FACUXTY EMPLOYEE T1�NMG Y N A <br /> E15 ;A1facili em to ees have received the ired on-thy" irairmn within the <br /> facility a 10 s hired within the E2ft 30 days have received the on-the-'ob <br /> Note; Any answer of"N"should be explained in the comment section on the followingan <br /> follow-rap action. l' d wall require <br /> Shirley Environmental Testing Corporation <br /> 9595 Lucas Ranch Road,Suite#Tilt},Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />