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Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: ( (IC r (,_) Date: <br /> Facility Address: n <br /> Cit : I Zip Code: 7 p <br /> Designated UST QErawr Conducting the tion: <br /> International Code Council Certification#: t'af 4 F.a iration Date: I f <br /> Signature: - Plione.(!26 `f - <br /> Y—Y —N NA- otAorticame <br /> Item MONITORING PANEL I ALARM HISTORY Y N NA <br /> 1 Monitoriu system is powered on and in proper operatmg mode. 41 1 <br /> 2 Monitoring system is not currently showing any alarms or warnings. -� <br /> 3 Alarm history zeport/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. (Attach a copy o the alarm history rertflo to this form if available.) <br /> 4 Each alarm for the previous month has been responded to ro riately. ,c <br /> 5 Sensors located in tank-to containment sumps have not alarmed in the past month. ,c <br /> 5a _ List all tank-top sumps where alarms occurred in the past month: ,tJ�N7✓ <br /> Note:Sumps where an alarm has occurred in the past month must be fnspected unless a quahj(ied service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach documentafion verifying appropriate service to this report: <br /> I sum ins n is Leguired,record results in item 6,belmv. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> -Nate:VPsual fn soman o sora s is only required to sumps where an alarm has rtccurred in the past month or which there is no service record <br /> Y N Y N <br /> sump Location: ( 1 l Sum Location: l 4 <br /> Sune Location: C-2 Sum Location: <br /> Sump Location: _ Sump Location: <br /> i <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1—Contents. �r ,Z Tank 3—Contents:. k! <br /> Tank 2—Contents.- Tank 4—Contents: <br /> S Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are located proped <br /> Y N NA Y N NA <br /> Dispenser 1/2 Di eraser 9110 <br /> Dispenser314 Dis <br /> penser 11/12 <br /> Dispenser S/b Dispenser 13 114 <br /> Dis user 7/8 Dis eraser 15116 L <br /> P"ERWORKINSPECTION Y N NA DATE DONE <br /> 9 Monitoring system certification has been cam leted within pag 12 months 2- r— <br /> 10 Secondary containment tests have been conVleted within the r uked bme m—e <br /> 11 Spill containment structure(bucket)testin was completed within the past year. <br /> 12 Tank timess testing was completed within required timeframe. <br /> 13 Line ti mess testi &was campleted within Leguired timefiarne. <br /> 14 Other uh-ed iestin maintenance was cam feted within fiirnefre. (List test/maintenanae items below) <br /> TesWainienance: -1 <br /> Test/Maintenance: <br /> TesWaintenartce: - <br /> I'ACILITY EMYLOYEIs TRAINING Y N NA <br /> 15 All facility employees have received the gAE!Edon-flheA trandn within the paAyear, <br /> 16 All facility a loyees hired within the jnst 30 days have received the required on the ob training. ,,C. <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 Cucamonga,CA 91730 <br /> $00-5334030 <br />