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Shirley Environmental Testing, Corp. <br /> Desigaated Underground Storage Tank (UST) Operator <br /> Monthly 'Visual Inspection Checklist <br /> F <br /> acility e: Date: _ess: Z' Code_ TeeST for Conductin the n ; �. <br /> International Code Council Certification# C Expiration Date:21114 I fig4 <br /> Si lure: Phone: 9 - L -qn <br /> YAY N=No NA— AppUcable <br /> Item MONMRING PANEL 1 ALARM HISTORY Y N NA <br /> 1 monitoring em is powend on and in ra mode. <br /> 2 Monitorin system is not amrently Aming any alarms or warnin . <br /> 3 Alarm history reportAog for the previous month is available,and has been reviewed by the y <br /> Designated UST O rotor. Attach a o the alarm Nista re rt/lo to this arm i avtlable. <br /> 4 Each alarm for The revious month has been nded to <br /> 5 Sensors located in lank-top containment have not alarmed in thepast mond,.. - <br /> 5a - List all lank-top sumps where alarms occurred in the past month: �)-S OQI <br /> Note:Sumps where an alarm has occur vd in tine past month must be Inspected unless a qualt)6ed service tachnician raspmWird to,and <br /> Pr, <br /> addressed,the cause of the alarm.Attach documentation iw7D5►ng appropriate smoke to this report <br /> T sum in tion is r red,record results in item 6,below. <br /> UST SYSTEM INSPECTION - <br /> 6 Tank lop containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:l/lsual inspection o wn s is onty mpnred to sumps where an alarm has ocaar:ed.tn the past month orwhich there is no service nnvrd <br /> Y N YI N <br /> Sunip Location: Ston .Location: <br /> Sump Lexahon: Sump Location: <br /> Sump Location: <br /> Sump Location: <br /> 7 Spill containment structures are free of water,debris and hazardous substance. <br /> Y N I NA Y N NA <br /> Tank 1-Contents: Y Tank 3-Contents: <br /> Tank 2-Contents. I LTJA I Tank 4-Contents: <br /> 8 Under4spenser containment areas are free of water,debris,and hazardous substances Sensors are I 3roperly, <br /> Y N NA Y ' N NA <br /> Dispenser 112 Dispenser 9/10 l f <br /> Dispenser 3/4 Dispenser.11112 <br /> Dispenser S/6 AA Dispenser 13 114 <br /> Di ser 7/8 Dis ser1S/16 104 <br /> PAPERWORKINSPECTION Y N NA DATE DONE <br /> 9 Monitoring tem certification has been completed witbin past 12 months. - <br /> 16 fy)y <br /> 10 $eco containment tests have been completed within the uired timeframe. <br /> 11 Sill coma=ent Amchrre[bucket testing was 2gTpleted within the past year <br /> 12 Tank ti tress te!tiM was com leted within r iuneframe. <br /> 13 Line ti mess tegiag was cam leted within required timeframe. <br /> 14 Other wired testis mainteimce was completed;-vithinrequired timeframe (List to maintenance items below) <br /> TesWaintenance: <br /> TesVMaintenance: <br /> TeAMaintenonce: <br /> p'ACELM EMPLOYEE TRAINING Y N NA <br /> 15 All facili em to ees have received the Enwed on-the tmaun witivnthe <br /> lti 1 All facility a 10 s hired within.the past 30 days have received the required on-the=ob trainin . <br /> Note: Any answer of"N"should be explained in the comment section on the following page.,and win require <br /> follow-up action. <br /> Shirley Environnnental Testing,Corporation <br /> 9595 Lucas Ranch Road,Suite#100,Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />