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Shirley Environmental Testing, Corp. -: Designated Underground Storage Tank(UST) Operator Monthly Visual Inspection Checklist Facility Name: o c_k -j S > - a We:' t a Co Facility Address: 3$U o ct.c, city-, c k c7 r+t .Zip Code: Desi ed UST operator ConducMg theInspection: 1 C 1 E A LZ=Q 'T r4�S International Code Council Certification#: 57_Cj y C.r I Expiration Date: o signature: Phone:(AL l ) G-6 Q W X�Yra,N=N NA=N'ot A lics'ble Item MONITORING PANEL I ALARM IIISTORY Y N NA I Monitoring system is powered on and in prooperatin mode. 2 Monitoring system is not currently showing any alarms or warnings. 3 Alarm history reportileg for the previous month is available,and has been reviewed by the Designated UST Operator. (Attach a copy a the alarm history re rt/ID to this form if available.) 4 Each alarm for the previous month has been responded to ro ri�afely. 5 Sensors located in tank-top oontainmrent n!Tps have not alarmed in the past month 5a List all tank-top sumps where alarms occurred in the past month: T'Z S'k" LOSS Q,e_wsl l Z- _ Note:Sumps where an alarm has accurrnd in the pastmonth must be inspected unless a palffied service teehnicfan responded to,and properly addr zs-ed,the cause of the alarm.Attaeh documentation verifying appropriate service to thisrd;P0A X'_.mp 2Wcnan is required,record results in item 6,belmv. UST SYSTEM INSPECTION 6 Tank-top containment sumps are free of water,debris,and hazardous substance. sensors are located properly- Note:Visual inspection o sma s is on re mired in sumps where an alarm has.oceurred in the past month or which ihere is no service record Y N A Y N tJ Sun2 Location: l_`1 Sulu Location: SIP C,,ck L-Li Sum-p Locadon: L-`t Sump Location: Sump Location: L - 5 Sump Location: 7 Spill containment structures are fie sof water,debris,and hazardous submnce. PA, oj T Y N NA e e - T-I Y N NA Tank 1--Contents. Tank 3-Contents. E,jt Tank 2-Contents: I Tarek.4-Contents: S Under-dispenser containment areas arc free of water,debris,and hazardous substance_ Sensors are located ro rdY_ Y N NA Y N NA Dir user 112 Dispenser 9110 Dispenser 3/4 PLSPenser 11/12 Dispenser 5/6 Dispenser 13 114 Dispenser 7/8 Desenser 15/15 PAPERV4tORKINSPECTIO14 Y N NA DATE DONE 9 Monitoring em certification has been completed within past 12 months. 10 Secondary containment tests have been co leted within the aired timeframe. b- Z -!S 11 Spill containment structure(bucket)testingwas con leted within the ear- 12 Tank ti esu testing was completed within r uined timefirame. - t3 Line tightness testing was ca leted with m required timeframe- l4 other uired testis maintenance was completed within required timeframe. (List test/maintenance items below) Test/Maintenance: T'est/Maintenance: T'es#Maintenonce: b'ACII 1TY EMPLOYEE'TRAINING Y N NA 15 All facility em to ees have received the required on-the= training within the past 16 All facilitya loyees hired within the post 30 days have received the required on-thejob traimin . Note: Any answer of"N"should be explained in the comment section on the following page,and will require follow-up action. Shirley Environmental Testing,Corporation 9595 Lucas Ranch Road,Suite#100,Rancho Cucamonga,CCA 91730 800-533-4030