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Sbirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> l4acilt Name: J ; Date: a 9 <br /> Facili Address: n Au e <br /> City: C�' -- C-�- <br /> Designated UST Operator Conducting theon: <br /> International Code Council Ceiiiticaiion#"` U iration Date: / I/d 1 <br /> Signature: ~�3-- I Phone:( c - <br /> YaY N=Na NA—Not Applicable <br /> Item MON rORMG PANEL/ALARM ffiSTORY Y N NA <br /> 1 Mo nitoring system is powered on and in mode- <br /> 2 Monitopng system is not currently sbowmg n alarms or wanuins <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi aced UST Operator. Attach aaoff o the alarm hidory report4og to flusform i aaailable, <br /> 4 Each alarm for the pE2ious month has been nded to ro ntel . <br /> 5 Sensors located in tank-to wntainment stwips have not alarmed in the past mon& <br /> 5a _ Last all tank-top sumps where alarms occurred in the past month: f�A <br /> Note:Swnps where an alarm has occurred in the past month mast be fnxpected unless a qualified service teehnidan responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation i,&7fong appropriate service to this report <br /> EMIf an is regidred.,record results In ftem 5,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank top conitainmcnt siririps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note.Visual Mspection o aum s is only to sumps where an alarm has-ocaured in the post month or which there is no service record" <br /> Y N", Y N— , <br /> Sum Location: c� urJr Lacaiion.f <br /> Sump,Location. <br /> Sump Locative: <br /> Sunip Location: ;*mp Location; ; <br /> 7 Spill containment structures are h=of water,debris and hazardous substance. <br /> Y J IN I NA Y I N I NA <br /> Tank 1—Contents: y6k 3—Contents.- <br /> Tank <br /> ontents.Tank 2—Contents: Tank 4—Contents.• <br /> 8 Under-dispenser contai ment areas are free of water,debris,and hazardous substance- Sensors are located erl . <br /> Y N NA Y N NA <br /> DiTenser 112 f ),4 Di erjser 9/1 o <br /> L>i ernser 3/4 Di enser 11/12 <br /> Dispenser 5/6Z 13114 yJ, <br /> Pis user 7/8 Dispenser 15/If TTA <br /> PAPERWORK INSPECTION Y NA DATE DONE <br /> 9 Moniwmg system certification has been completed within past 12 months <br /> 10 Seca coanhainment tests have been completed within the wired timeframe. D <br /> 11 Spill containment Ma uctm(bucket was completed within the past year. <br /> 12 Tank d4itness testing was con leted within LcqjjLaj timeframe. <br /> 13 line lightness testing was completed within required timeframe. A) / i <br /> 14 Otber required testin maintenance was co feted within timeframe. (List testlm ntenance r below-) <br /> Test/Maintenance: <br /> Test/Matntenance: <br /> Test/Maintenance: <br /> FAC rrY EiY LOYEE TRAFUNG Y N A <br /> 15 All facili era to em have received the Mguircd onwtlie-job trainin within,Me pst ym. <br /> 15 All facility a la s hired within the past 30 days have received the on-the-job <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> follow-up action. <br /> Shirley Environmental.Testing,Corporation <br /> 9595 Lucas Ranch Road,Suite#100,Rancho CucamonA CA 91730 <br /> 800-533-4030 <br />