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11/06/2007 TUE 12:07 FAX 209 937 5846 Q005/016 <br /> Shirley Environmental Testing, Corp. <br /> • Designated Underground Storage Tank(UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: .I., Date: <br /> Facility Address* <br /> City- Zip Code: 6'1_r- <br /> Designated UST Operator C6nducling the Inspection: <br /> International Code Council Certificatign#: Expiration Date:Z. 1 <br /> Signature: L <br /> 1, <br /> Phone:(1'1�( <br /> Y—Y— N=NID NA=NotAvrtcabk <br /> Item MONMRINGTANEL I ALARM MSTORY JYJ N NA <br /> I Monitonm system is powered an and in proper operating <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 has been reviewed by the <br /> Designated UST Operator. (Attach a copy YLIze alarm history re�rMto this form i <br /> favailable) <br /> 4 Each alarm for The pmrious month has been responded to ap 'propn -ate <br /> ly. <br /> 5 Sensors located in lank-top containment sum s have not alarmed in the past month. <br /> 5a List all lank-top sumps-where alarms occurred in the past month: �"11-a0— <br /> Note;Sumps where an alarm has occurred in the post month must be inspected unless a qualified service technician responded to,and <br /> properly addressed,the cause ofthe alarm.Attach documentation verifying appropriote service to this report. <br /> ysump itis --tion is re aired,record results in Item 6,below. <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> ',Vote:usual inspection or.iymps is ani v requi inSum psinhere an alarm has-.occurred in the post month Lbrwhich there is no service,record. <br /> Y N <br /> Sunt p Location: en. , t Sump Location: i. <br /> Sum Location: 1. Sump Location: <br /> Sump Location: Sump Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y I N I NA I L Y N NA <br /> Tank 1—Contents: t,I Tank 3—Contents: <br /> Tank 2—Contents: I Tank 4—Contents. <br /> 8 UndeL snsQr containment areas are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Y N NA Y N I NA I <br /> Dispenser 1/2 K Dispenser 9110 <br /> Dispenser 3 14 Dispenser 11112 <br /> Dispenser 5/6 ,Dispenser 13 14-LsTe-n ser 7/8 Dispenser 15 16 <br /> PAPERWORK INSPECTION Y, N -NA DATE DONE <br /> 9 Monitoring& <br /> ystem certification has been completed within past 12 months- <br /> 10 Secondary containment tests have been completed within the uired timeframe. <br /> 11 SpiU oontainuient structure(bucket)testing was comi�)lietre,-da�witbin.ilio past ear. <br /> 12 Tank tightnm testing was completed within Leguired timeframe. <br /> 13 Line tightness tesft was cwnpleted within required timeframe. <br /> 14 Other required w*g/maintenance was co lipleted within regaired timeftame-.(List test/maintenance items below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Zest/Maintenance: <br /> FACMrrY IEMLOYEIF,TRAUqNG Y N NA <br /> M15 1 All facili!y employees have received the required an-th job tradnin -with )e aA--ir. / <br /> 16 All facility empl2Lees hired within the past 30 days leave received the required on-the-j-,training. <br /> Note: Any answer of"N"should be explained in the comment section on the following pace,and will reoire <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 />