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Shirley Environmental Testing, Corp. <br /> • Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: 7c v 7o] C ( Date: <br /> Facili Address: �} C CIYbA CIA2br✓E <br /> City, Zip Code: Sa G <br /> Desi ed UST Operator Conducting jLjn: 4 u 3 <br /> International Code Council Certification 41. CV: 0 wation Date: I I[p <br /> Signature: I Phone:(Y 0 ) WO I <br /> - <br /> Y o Ym N=No.NIA Not Applicable <br /> Renu MONITORINGPANEL I ALARM HISTORY JYJ lY INA <br /> 1 Morutorin system is powered on and in pppq o mode. <br /> 2 Monitoring system is not cunrAigy showinalarms or warnings. <br /> 3 Alarm historyreport/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. Attach a.M qf the alarm history repodft to this arm i available.) <br /> 4 Each alarm for the previous month has been respondo to appmpnately. <br /> 5 Sensors located in tank-top containment FIM have not alarmed in the past month. <br /> 5a .List all tank-top sumps where alarms occurred in the past month: Q+� <br /> Note:Swaps where an alarm has occurred in the past month must be inspected unless a qualified service hwhniclan responded to,and <br /> properly addressed,the cause ofthe alarm.AUach documentation iw'rfying appropriate service to this report <br /> I sum Ins on is r ed,record results in item 6,beltne. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> IJate:Trseal inspection of sum sIs reqaired ht= s where an alarm has occwred.In the st month orwhich there Is rto sergl recor4. <br /> Y N Y N <br /> ,Sum .Location: �- Sum Location: l- <br /> Sum Location: ( 7 / Sump Location: <br /> Sum Location: L- Sum Location: <br /> 7 Spill containment structures are free of water,debris,and haaardous substance. <br /> A_ f TpJU K Y I N NA '(O_o TM)K Y N NA <br /> Tank 1--Contents: ,I Tank 3-Contents: (i <br /> Tank 2-Contents: Al I Tank 4-Contents.- <br /> 8 <br /> ontents.S Under-di user containment areas are free of water,debris,and hazardous substance. Sensors are loGittedWrope <br /> Y N NA Y N NA <br /> Dispenser 112 ✓ Dispenser 9110 <br /> r� <br /> Di eraser 3/4 Dispenser 11/12 ✓ <br /> Dispenser 5/6 Dispenser 13114 ✓ <br /> Di ser 718 ✓ Dispenser 15116 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitorinsystem certification has been leted within past 12 months. ✓ - CS <br /> l Q Secondary have beear co leted within the required timeframe. 1 T N-oS <br /> 11 Sill containment structure(bracket was com leted within the ear. l/ 5 <br /> 12 Tank ti mess tegirig was completed witliW required timeframe. ✓ Q/J-rWo.) <br /> 13 1 Line ti tees testing was completed within rquired timeframe. <br /> 14 Other aired testin maintenance was cam leted withinrurnred timeframe. (List test/m unienanre items below) <br /> Te"aintenance: <br /> Test/Maintenance: <br /> Test/Mainlenanee: <br /> FACILITY EMPLOYEE TRAINING Y),N NA <br /> 15 All faGility employees have received the requircul on-the trainm within the gaA X= <br /> 16 All facility 2ffLoyees hired within the 22st 30 days have received the required on-_the^ob bainin . <br /> Note: Any answer of"N"should be explained in the comment section on the following page,and will require <br /> foAow-up action. <br /> Shirley Environmental Testing Corporation <br /> 9595 Lucas Manch Road,Suite#100,Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />