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Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank (CYST) Operator <br /> Monthly Visual Inspection Checklist <br /> Fa0ky Name: 1 7" i -i) Date: <br /> Facility Address. 0-7 Nib [/ . <br /> Cit - S te-T-ON CA I Zip Code: 1:52 p <br /> ` <br /> Designated UST Operator Conducting theInspection: 4 iA,;r . 6 r <br /> International CoAe Co "1 Certirmcation#: 5.2,4 1 3q- t �-- I Fa iration Date: 1 Z 12'7 1 cD Gv <br /> Signature: 71/93 <br /> Y—YM N—NP NA-Not n Beale <br /> IYcrn MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoring system is wered on and in p=qpgatijn mode -Y <br /> 2 MonAoring system is not tmrrently showing any alarms or warnings. <br /> 3 Alarm history repor0og for the previous month is available,and has been reviewed by the <br /> Designated UST Operator, Attach a co o the alarm history re rt/!o to this form if available.) <br /> 4 Each alarm for the previous month has been nded to Mppnat ' . <br /> 5 Sensors located in tuk-top containment sumps have not alarmed in the pst montb- `t <br /> 5a List all tank sumps where alarms o rred in the past month:�,• L' L- <br /> 00 t� , �500)TO/ZrZIZ i/ lf'it1 1e)-�J AI�l � ��16,5�!Dt.y� �u.Sf �� N,4JAi <br /> Note:Sumps where an alarm has occurred in the past month mast be tnspeaed unless a gualiied service technician responded to,and <br /> properly addresses the cause of the alarm_Attach documentation verifying appropriate service to this report <br /> #—s—m#-s-mp fns on is required,record results in item 6,helm-. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located pmperly. <br /> Note.usual inspection o sum s isly r aired in sum s where an alarm has occaared in the post month or which there is no service rr.cord. <br /> �. Y N Y N <br /> Sunt Location: C , 1 Sump Luca ion <br /> Sttm Location: - 4 Sum Location: <br /> Sum Location: [ - &mp Location: <br /> 7 Sin containment strwtures are free of water,debris,and hazardous.substance. <br /> Y N NA Y N NA <br /> Tank 1-Contents.`r- }C Tank 3-Contents: <br /> Tank 2-Contents. W Tank 4-Contents- <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous Substance. rs are located pr9perHy. <br /> Y N NA Y N NA <br /> Dispenser 1121 Di eraser 9/10 <br /> Dispenser 3/4 Di3penser 11/l2 <br /> Dispenser 5/G Dispenser 13 114 IVI LT <br /> _2Lsffnser 7/-8 Dis enser 15116 <br /> PAPERWORK INSPECTION Y N INA DATE DONE <br /> 9 Monitorin system certification has been completed within past 12 months. 17-2 -Os- <br /> 10 <br /> OS10 Sero containment tests have been co feted within the required timeframe. 2 -,:D, <br /> � <br /> I 11 S ill containment structure(bucket)testing was completed within the past year. <br /> 12 Tank gotgessjesting was completed within required tinnefraine_ <br /> 13 Line lightness trs!!gg was completed within required timeframe. 4L]AJ <br /> 14 Other requircd testin npaintenance was cam feted within timetiamt (List test/ma ntenance items below) <br /> Test/Maintenance: (--Cj(,�A s kA-,oCi 1 r✓C) 0-.2-7 Q S <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility em io ees have received the required on-the training with the year. <br /> 16 All facility employees hired within the st 34 days have received the rewired on-the=ob training. <br /> Note: Any answer of"N"should he 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 4100,Rancho Cucamonga,CA 91730 <br /> 500-533-4030 <br />