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UNDERGROUND STORAGE TANK DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 2 of 2 VII . INSPECTION HISTORY Y N Has each follow-up action of section III from the previous inspection been completed appropriately? Attach documentation verifying 8Dpr0prjete service to this report.) DIM VIII . ALARM HISTORY Attach a copy of the alarm history report/log to this report, Y N NA Is the monitoring system powered on and in proper operating mode? ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ® ❑ ❑ (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 service technician? ® ❑ ❑ List below In section 1X, all containment sumps that have had a leak detection alarm since the previous inspection and have not been responded to by a qualitred UST service technician. Containment sumps listed below require a visual Inspection for damage, water, debris, hazardous substance and pMer sensor location, The results of the visual ins ectlon must be recorded /n section IX. IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of damage , water, debris, and hazardous substance? Containment Sump ID Y dN Containment Sump ID Y NRUL-Fill 0 DSL-Fill ® ❑RUL-STP-Sum ® DSL-STP Sum ® ❑ PUL- Fill ® N/A ❑ ❑ PUL-STP-Sum ® N/A ❑ ❑ 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 RUL- Fill 10 ❑ DSL- Fill ® ❑ PUL-Fill ® ❑ N/A ❑ p Is the fill pipe free of obstructions? TANK ID RUL- Fill ® 11DSL- Fill ® ❑ PUL- Fill 10 1 ❑ I N/A ❑ ❑ Is the fill cap securely on the fill pipe? TANK ID RUL- Fill 10 10 1 DSL-Fill 01 ❑ PUL-Fill ® 10 1 N/A ❑ ❑ Is the under-dispenser containment free of damage , water, debris, and hazardous substance? Under-dispenser Containment ID Y N N Under-dispenser Containment ID Y N NA Dispensers 1 -2 ® ❑ ❑ ❑ ❑ Dispensers 34 ® ❑ ❑ ❑ ❑ Dispensers 5-6 ® ❑ ❑ ❑ ❑ Dispensers 7-8 ® ❑ ❑ ❑ ❑ on Dispensers 9- 10 ® ❑ ❑ ❑ 11 Dispensers 11 - 12 ® 01 01 ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ® ❑ ❑ X. TESTING AND MAINTENANCE Y N NA DATE PERFORMED Has the monitoring system certification been completed within the past 12 months? ® ❑ 3/25/19 Has the spill container testing been completed within the past 12 months? ® ❑ 3/25/ 19 Has the overfill prevention equipment inspection been completed within the past 36 months? ® ❑ ❑ 3/25/ 19 Has the secondary containment testing been completed within the past 36 months? ® ❑ ❑ 3/5/18 Has the tank tightness testing been completed within required timeframes? ❑ ❑ ® PLLD Has the line tightness testing been completed within the required timeframes? ❑ ❑ ® CSLD Other re wired testing I maintenance was completed within required timeframe. List tesbmaintenance items below. Test / Maintenance: AQ-T@Stin ® ❑ 3/20119 Test / Maintenance: Sections VII thru XLL Continuous in tank leak detection method ® El Test / Maintenance : TLS-350 PLLD line testing See Alarm histo report . * ® ❑ Test I Maintenance: El ❑ Test / Maintenance: ❑ 1 n tHave t / Maintenance : ❑ ❑ XI . FACILITY EMPLOYEE TRAINING Y N ll individuals performing facility employee duties received the required facility employee training within the past 12 months? ® ElI If the facility has more components than this form accommodates, additional copies of this page maybe attached. I Y = Yes, N = No, NA = Not Applicable, ID = Identification i E