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[a 011/016 <br /> 11/06/2007 TUE 12:08 FAX 209 937 5846 <br /> > t <br /> t <br /> Job #; <br /> Environmental Corporation <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly ,Visual Inspection Checklist <br /> Facilit Name: Date: <br /> Facility Address: <br /> Cit Zip Code: <br /> Desi ted UST Operator Conducting the ecdon <br /> Jute= oral Code Council Cerlification#: _ ` 7c iratian Date:' <br /> Signature: Phozre:( . , <br /> No NA m Not Arplimbic <br /> I nR MONITORING PANEL ALARM HISTORY I Y j N NA <br /> I Monitoring system is wered on and ui proper operating mode. <br /> 2 Monitoring system is not currently showing any alarrrus or warnings. <br /> 3 I�lann history report/log for the previous month.is available,and has been reviewed by flue <br /> Designated UST Operator. (Attach a c2a of the alarm history Lo rt/lo to this,Torrn i uvailabJe. <br /> 4 Each alarm for the pEeyious month has been responded to a ro dately. <br /> 5 Sensors located in tank-to containzuent sum shave not alarmed i i the 5-Lmonth. <br /> Sa List all tank-top sunips where alarms occurred in the post month: <br /> Note:Sumps where an alarm has occurred in the past month must be Inspected unless a qualified service technician responded to,and <br /> prdperiy addressed,the cause of fhe alarm.Attach documentation verifying appropriate service to This report <br /> J sum ins inn is re aired,record results in item 6,below. <br /> UST SYSTEM INSFECTION <br /> 6 Tank-top contaiaument siunps are free of water,debris,and hazaidpi s substance. Sensors are located properly. <br /> Nofa:T�sual inspecrion o sum sit orf ra aired in sum r where on alarm has occurred in the at nranth or which there rs noY it record. <br /> • <br /> Y N <br /> Sum <br /> Sump Location: <br /> Location: <br /> Sump Location:-: Sum Location: <br /> Sunip Location: Sunt Location: <br /> 7 S ill containment structures are free of water,debris and hazardous substance. Y N NA <br /> Y N NA <br /> Tank 1—Contents: Tank 3—Contents: <br /> Tank 2—Contents: : Tank 4--Contents: <br /> 8 Under-diguser contaimnent areas are free of water, is,and hazardous substance. Sensors are IocatY )r Y. <br /> Y N NA <br /> Dispenser 1/2 w;, Dispenser 9110 <br /> Dispenser 3/4 Dispenser 11/12 <br /> Dis enser 516 Dis enser 13/14 <br /> Dispenser 718 Dispenser 15/16 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Manitorin stem certification has been completed within st 12 months. <br /> 10 Secondsg containment tests have been co feted within the required timeframe. <br /> _L1 Sill containment structure(bucket)testing was completed within the past ear. <br /> 12 Tank tightness testing was completed within required timeframe. <br /> 13 Line ti tress testing was conn leted within required tbnefrarne. <br /> 14 Oilier required ttsstin maintenance was completed within r uired timeframe. (List testImaintenance items below) <br /> Test%LSaintettance: <br /> Test/Maintenance: <br /> TesdMaintenanee: o <br /> 0 <br /> FACILITY EMPLOYEE TRAINING Y N NA 7 <br /> 15 All facili employees leave received the re aired on-the-' trainin within the past year. tr <br /> `` <br /> yees Wed within.the past 30 days have received the uired on-the job training. 6 <br /> 6 pEf—acility S22LO6 <br /> Note: Any answer of"NN"should be explained in the comment section on the following page,and will require 05 <br /> follow-up action <br /> Shirley Envirronmenta19l Co" 0ration, 9595 Luccts Ranch Ref., Ste. 100, Rancho Cucamonga, CA 91730 <br /> Tel. (909) 476-7443 • Tall Free: (800) 533-40.30 • Fax: (909) 4767114 - CA Lic. #814027A HAZ <br /> Page I of 2 <br />