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Apr 18 2018 1435 HP Fax page 2 UNDERGROUND STORAGE TANK DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT ( Page 2of 2 ) VII . INSPECTION HISTORY Y N Has each follow-up action of section III from the previous inspection been completed appropriately? ® ❑ ' Attach documentation ve n a pro nreate service to this ort- Vlll . ALARM HISTORY Attach a copy of the alarm history reportflog to this report. Y N NA Is the monitoring system powered pn and in proper operating mode? I@ ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ® 13 11(Attach documentation verifying appropriate service to this report.) Have all containment sumps , that have had a leak detection alarm since the previous inspection , been responded to by a qualified UST ® 11 11service technician? List below in section DC, all containment sumps that have had a leak detection alarm since the previous inspection and have not been responded to by a qualified UST servicb technician. Containment sumps fisted below require a visual inspection for damage, water, debris, hazardous substance and pronr sensor location. The results of the visual in action must be recorded to section /X IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of damage, water, debris, and hazardous substance? Containment Sump ID Y N Containment Sump ID Y N T1 : Regular- STP ❑ ❑ El El Premium- STP ❑ ❑ ❑ ❑ T3: Diesel- STP ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? ❑ ❑ Is the spill container free of damage , water, debris, and hazardous substance? TANK ID T1 : Regular ® ❑ T3 : Diesel ® � Q T2 : Premium ® ❑ ❑ [t ; Is the fill pipe free of obstructions? TANK ID T1 : Regular ® ❑ T3: Diesel ® ❑ T2 : Premium ® ❑ ❑ p Is the fill cap securely on the fin pipe? TANK ID T1 : Regular ® ❑ T3 : Oiesel ® ❑ T2: Premium ® ❑ p ❑ Is the urcteredispenser containment free of damage, water, debris, and hazardous substance? Under-dispenser Containment ID Y I N Under-dispenser Containment ID Y N NAI 1 /2 ® El 11 ❑ ❑ 3/4 ® ❑ ❑ 11 ❑ 5/6 ® ❑ ❑ ❑ ❑ 117/8 ® ❑ ❑ ❑ ❑ ❑ 9/ 10 01 01 ❑ ❑ or ❑ 11 !12 ® ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ® ❑ 1 d X . TESTING AND MAINTENANCE Y N NA DATE LAST Has the monitoring system certification been completed within the past 12 months? PERFORMED 101 El 12/11118 Has the spill container testing been completed within the past 12 months? 10 ❑ 12/11 /18 Has the .overfill prevention equipment inspection been completed within the past 36 months? ® 11 EI 12/11 /18 Has the secondary containment testing been completed within the past 36 months? ® ❑ ❑ 1 /24/18 Has the tank tightness testing been completed within required timeframes? ❑ ❑ ❑ Has the line tightness testing been completed within the required timeframes? ❑ ❑ ❑ Other required testing / maintenance was completed within rwuired timeframe . List testfmaintenance items below. Test / Maintenance: Air Quality test 01 ❑ 12/11 /18 Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ I I Test / Maintenance: ❑ ❑ 1 r- XI . FACILITY EMPLOYEE TRAINING I Y N Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? ® ❑ If the facility has more comoonente than this form wcnmm^4. #&)s, additional copies of this page may be attached. Received Time Dec , 20 . 20 .18 1 : 10P9 No , 4501 Y = Yes. N = Na NA = �t Aoolicahle. 10 = Iderthficabon