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} Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> F'acilityName: S-� -�jh (A L- , Date: cry D <br /> Facility Address: �6 O v L,n A <br /> Cit . S-T I,-4 Z' Cade: C1 S <br /> Designated UST Operator Conducting the Inspection: 'Jun'C (s <br /> International Cade Council Certification# rti I E. iration Date: <br /> Si ature: Phone:{ ) <br /> Y =JV NA—Not A livable <br /> item MONITORING PANEL/ALARM MSTORY Y N NA <br /> 1 Monitoring system is powered on and in proper operating mode- <br /> 2 Monitoring system is not currently showing any alarms or warms . <br /> 3 Alarm history reporlllog for the previous month is available,and Inas been reviewed by tate <br /> Designated UST Operator. (Attach a eo y of the alarm histo repori/lo to this form if available.) <br /> 4 Each alarm for the previous month has beenres nded to appropriately, <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. <br /> 5a List all tank-top sumps where alarms occurred in the past month: O <br /> Note:Sumps where an alarm has occurred in the past month must be Inspected unless a qualified service taehniclan responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation verifying appropriate sawce to this report, <br /> lfsump Fns on is required record results in item 6,belrnv. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top conal mrent surnps are free of water,debris,and bazardous substance. Sensors are located properly. <br /> Note_Visual inspection o smn s is only required in su rwhere an alarm has occurred in thepost month or which there is no service record. <br /> Y N Y N <br /> Sump Location: L- Sum Location - <br /> Sump Location: L- SumP Lavation: <br /> Sump Location: L- Sump Location: <br /> 7 §i11 containment structures are free of water,debris and hazardous substance. <br /> Y I N NA Y N NA <br /> Tank l—Contents: 50,11 _6,k 4-- d/ Tank 3—Contents.- <br /> Tank <br /> ontents.Tank 2—Contents: ' I X Tank 4—Contents' <br /> 8 Under-di nser containment areas are free of water,debris,and hazardous substance. Sensors are locatedro rl . <br /> Y N I NA Y N NA <br /> Dispenser 112 x,�C Dispenser 9110 >,- <br /> Dispenser <br /> ,-Di enser 3 14 X Dis enser 11/12 -4 _ <br /> Dispenser 5/6 Dispenser 13114 <br /> Dispenser 718 X Dispenser 15116 <br /> PAPERWORK INSPECTION Y N NA PATE DONE <br /> 9 Monitoring stem certification has been completed within past 12 months. V - o - O <br /> 10 Second containment tests have been completed within the required timeframe. 0Z <br /> 11 SpA containmeut structure(bucket IEMM was completed within the ear. �. <br /> 12 Tank tightness testing was completed within required timeframe. J <br /> 13 Line tightness testing was completed withinaired timeframe. <br /> 14 Other requinA testis maintenance was com leted within required timeframe. (List tesdmainfenance items below) <br /> Test/Maintenance:Test/maintenance: <br /> TestlMaintenance_ �— <br /> 'FACILITY EMPLOYEE TRAINING Y I N NA <br /> 15 Allfacilityem o ees have rceeived theed on-the-,job!raisin within the <br /> _p�g year <br /> 16 All facility employees hired witWn the,past 30 days have received the Tguired on-the-job training. -�_ EEJ <br /> 1: Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> t' follow-up action. <br /> Shirley Environmental Testing,Corporation <br /> 9595 Lucas Ranch Road,Suite#100,Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />