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Shirley Environmental Testing, Corp. <br /> Designated Underground Storage Taub (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> hacilit Name: Date: <br /> Facility Address: r�? <br /> Cit . zip Code: Q <br /> Desi ed UST Operawr Conducting the on: r <br /> International Code Council Certification#: 5 <br /> IExpiration Date: I <br /> Signature: Phone: t <br /> Y-YmN-N PIA-NotA Hrabk <br /> Item MONITORING PANEL I ALARM HISTORY Y N NA <br /> 1 Monitoring em is powered on and in proper operating mode. <br /> 2 Monitoring system is not currently showing any alarms or warnings. <br /> 3 Alarm history report4og for the previous month is available,and has been reviewed by the <br /> Designated UST Operator. (Affach a c,.?py!3f the alarm histo rert/lo to this form i available. <br /> 4 Each alarm for the ppqious month bas been nded toro nately. <br /> 5 1 Sensors located m tank-ta containment sumps have not alarmed in the past month. <br /> 5a - List all tank-stop sumps where alarms occurred in the post month.- <br /> Note. <br /> onth:,Note.Sumps where an alarm has occurred in tare past month must be inspeaed unless a qualrf ed service techniciatr responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation iwV5 ing appropnote service to this report <br /> 7 sum in 'an is r ed,record results in ttem 6,beLnv. <br /> UST SYSTEM INSPECTION <br /> 5 Tank-top containment sharps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note.Fisual inspection asum s is an r aired in sum s where an alarm hasacclared.in the stmouth or which there is no service record. <br /> Y N Y N <br /> Swup Location: L sump Location: <br /> Sum Location - Al' Sump Location: <br /> Su)7]P Location: L` ,Sump,Location: <br /> 7 Spill containment s€ructmes are free of water,debris,and hazardous substance. <br /> lk Y I N I NA I e I-ow 14n[t Y N NA <br /> Tank 1-Contents: Tank 3-Contents: 1 <br /> Tank 2-Contents: Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance_ Sensors are located 3ropedy. <br /> Y N NA Y N NA. <br /> Di neer <br /> 112 Di eraser 9110 <br /> .� <br /> Dispenser 3/4 P!s Penser 11/12 <br /> Di eraser 5/6 Di eraser 13 114 <br /> Dispenser 7/8 Die enser 15/16 <br /> PAPERWORSINSPECTION Y N NA DATE DONE <br /> 9 MordWring Ustem certification has been com leted within past 12 months. <br /> 10 Secondary containment tests have been completed within the uired tmidarme: Q. <br /> 11 Sill containment structure(bucket)testin was completed within the year. <br /> 12 Tank J tress testin was comp leted within required timeframe. ✓ -1�'V M- <br /> 13 Line tightness tsstin was completed within required timeframe. <br /> 14 Other wired testinmaintenance was completed within timeframe. (List test/malntenamae items belum) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACMYff EMPLOYEE TRAPfWG Y N NA <br /> 15 All facility employees have received the required on-the twning within the <br /> 16 All facility employees hired within the R2Lt 30 days have received thewired on-the=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 4100,Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />