Laserfiche WebLink
y � <br /> Shirley Environmental Testing, Corp. <br /> i Designated Underground Storage Tank (UST) Operator <br /> �! Montbly Visual Inspection Checklist <br /> Facility Name: a C- ort a+ Date: 1 0(a <br /> Facility Address: r,,a. <br /> 91T S. 41c o .j trA Zip Cade: °15 20 G <br /> _pqg2ated UST Operator Conducting the ection: (L 1 C- 2-2 S <br /> International Code Council Certification#: fo- Q(- IExpiration Date: I7, 1 o <br /> Signature: Phone:( (o } 21(0- (.04 D <br /> Y='Yes,N=N NA-Nat A licable <br /> Item MONITORING PANEL/ALARM HISTORY Y I N NA <br /> 1 Monitoring stem is veered on and in proper operating node. <br /> 2 lvionitorin system is not LA ntly showin any alarms or warnings. AC <br /> 3 Alarm history reportilog for the previous month is available,and has been Xevie owed by the v <br /> Designated UST Operator. (4itach a copy o the alarm history report/log to this form i available.) d� <br /> 4 Each alarm for the previous month has been nded to a ro mately- <br /> 5 Sensors located in tnk-top containment sum have not alarmed in the Past moniti. <br /> 5a List all tank-top sumps where alarms occurred in the past month: <br /> .Note:Sumps where an alarm has occurred in thepasr month musr be in.7paeted unless a qualified service Leckrtcian respw ded to,and <br /> properly addressed,the cause of the alarm.Attach documentation zwrfying appropriate service to this report <br /> sum ins on is r red,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 looted properly_ <br /> Note:Visual inspection o son s is re 'red in sum s where an alarm has occurred in the q month or which there is no service.record <br /> Y N Y N <br /> Sup: Location: -t P Sum Location: <br /> Sum Lcrcatiarr: }�5T Sum Lacatlon: <br /> Sump Location: Sump Location: <br /> 7 Spill containment structures are free of water,debrir,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1-Contents: S L S T Tank 3-Contents: <br /> Tank 2-Contents: t- A c Tank 4-Contents: <br /> 8 Under-dispenser containment areas are free of water,debris,and hazardous substance. Sensors are low 3roperdy. <br /> Y N NA Y N NA <br /> Dispenser 1/2 Dispenser 9110 <br /> Dis eraser 3/4 Dispenser 11/12 <br /> Di eraser 5/6 <br /> Dispenser 13114 <br /> Dispenser 7/8 Dispenser 15116 <br /> PAPERWORK INSPECTION Y N NA DATE DONE <br /> 9 Monitorin teen certification has been completed within past 12 months. -as <br /> 10 Secondary containment tests have been.Co feted within the aired timeframe. U` -e <br /> 1 i Sill containment structure(bucket testing was caa feted within the year x v ~Z$ (:' <br /> I 12 Tank tiess stir was coo leted within r timeframe. ✓ o <br /> 13 Line tightness testing was completed within required timeframe- <br /> 14 Other Inuired to maintenance was cooleted within timeframe {List test/maintena�ce items below.) <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING YJ N 1NA <br /> 15 All facility employees have received the requized on-the-job trwiiin within the ast ear. <br /> 16 All facility a loyees hired within the Lmst 30 days have received the aired 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 Manch Road,Suite#100,Rancho Cucamonga,CA 91730 <br /> 800-533-4030 <br />