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Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Tank {UST} Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: 5 c)xl , Date: <br /> Facility Address: o C <br /> City' }t zip Code: c! �a <br /> Desi ed UST Operator Conducting the Inspection: fPJ f, <br /> / <br /> International Code Council Certification#: el J t,(..'U C I a- iration Date: 7 Q 1 10 <br /> Signature: Phone:( p ),V <br /> Y=Yea,N=No NA—Not A licable <br /> Item MONITORING PANEL/ALARM HISTORY 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 warnings. <br /> 3 Alarm history report/log for the previous month is available,and leas been reviewed by the <br /> Designated UST Operator. Attach a copy of the alarbi history reportl7qg to this form,i available.) <br /> 4 Each alarm for the previous month has been responded to appro riately. ' <br /> 5 Sensors located in lank-top containment sumps have not alarmed in the Pst mouth. <br /> 5a .List all tank-top smnps where alarms oecurredin the past month: <br /> Note:Sumps where an alarm has occurred rn the past month must be Inspected unless a qualified service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation rerifong appropriate service to This report <br /> 7 sum ins Y n is required,record results in item G,belmr. <br /> [i <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and bazardous substance. Sensors are located properly. <br /> Nate:Visual inspection o sum s is only re iced in-sum s where an alarm has occiared in the st month or which there is no service record. <br /> Y N Y N .' <br /> qEm.Location: (,,� Sump Locafion: < <br /> &mp.Location: -2- Y:,, :: Sump Location: <br /> Sump.Location: Sump Location: - <br /> 7 Spill containment structuress are free of water,debris and hazardous substance. <br /> Aaog -r'fs Y N NA I -r-"V- Y N NA <br /> Tank i-Contents: , j( 'rank 3-Contents: Fzjk <br /> Tank 2-Contents: Tank 4-Contents' <br /> 8 Under-dispenser containment areas are free of water;debris,and hazardous substance. Sensors are located ?roperly. <br /> Y I N INA Y N NA, <br /> Dis nser 112 Dispenser 9116 <br /> 2i Tenser 314 Dispenser II/12 <br /> Di enser S/6 Dis enser 13/14 <br /> Dispenser 718 Dispenser I51I6 <br /> PAPERWORK]NSPECTION Y N NA DATE DON) <br /> 9 Monitorin Eystm certification has been co leted within past 12 months. -0< <br /> 10 Secondary containment tests have been co feted within the required ti.mefiame. <br /> 11 Spill containment struchrre(bucket testing was completed within the ear. JS <br /> 12 Tank tightness testing was completed within required timeframe. rwo7 A <br /> 13 Line tightness testing was completed within required timeframe. <br /> 14 Other required testis maintenance was completed within required timeframe. (List test/maintenanm items below.) <br /> TesNMainfenance: <br /> Test/Mointenance: <br /> Test/.M'aintenonce: ✓ <br /> FACILM EM LOYEE TRAINING Y N NA <br /> 15 All facil% employees have received the required ori-the b traiuin within the ear. <br /> Of <br /> 15 All facility employees hired within the past 30 days have received the required om thea ob training. <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 /> 800-533-4030 <br />