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UNDERGROUND STORAGE TANK DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Pa e 2 of 2milli ) Vil . INSPECTION HISTORY I Y LN Has each follow-up action of section ill from the previous inspection been completed appropriately? ® ❑ Attach documentation verifying appropriate service to this report.) Ville ALARM HISTORY Attach a copy of the alarm history report/iog to this report. Y NINA Is the monitoring system powered on and in proper operating mode? 19 ❑ ❑ 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 ® ❑ C1 service technician? List below In section IX, all containment sumps that have had a leak detection alarm since the previous Inspection and have not been responded to by a qualified UST service technician. Containment sumps listed below require a visual Inspection for damage, water, debris, hazardous substance and proper sensor location. The results of the visual Ins ecdon must be recorded in section IX. 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 RUL-Fill ® ❑ DSL-Fill ® ❑ RUL-STP-Sum ® ❑ DSL-STP Sum ® ❑ PUL-Fill ® ❑ E03 ❑ PUL-STP-Sum ® ❑ ❑ ❑ 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 ® ❑ DSL- Fill ® ❑ PUL- Fill ® ❑ 01 ❑ Is the fill pipe free of obstructions? TANK ID RUL-Fill 10 10 1 DSL- Fill ZI ❑ PUL-Fill ® ❑ ❑ ❑ Is the fill cap securely on the fill pipe? RUL-Fill ® ❑ DSL- Fill ® ❑ TANK ID PUL-Fill ® ❑ ❑ ❑ Is the under•dispenser containment free of damage, water, debris, and hazardous substance? Under-dispenser Containment ID Y N N UnderAlspenser Containment ID Y N N Dispensers 1 -2 ® ❑ ❑ ❑ ❑ ❑ Dispensers 3-4 ® El El ❑ ❑ ❑ Dispensers 5-6 ® ❑ ❑ ❑ ❑ ❑ Dispensers 7-8 ® ❑ ❑ 171300 Dispensers 9- 10 ® ❑ ❑ ❑ ❑ ❑ Dispensers 11 - 12 ® ❑ ❑ 01010 Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ 1 ❑ 111 X. TESTING AND MAINTENANCE Y N NA DATE LAST PERFORMED Has the monitoring system certification been completed within the past 12 months? 10 ❑ 3/5/ 18 Has the spill container testing been completed within the past 12 months? ® ❑ 3/5/ 18 Has the overfill prevention equipment inspection been completed within the past 36 months? 10 ❑ 01 12/28/ 18 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? ❑ ❑ 01 PLLD Has the line tightness testing been completed within the required timeframes? ❑ ❑ 01 CSLD Other required testing I maintenance was completed within required timeframe . List test/maintenance items below. Test / Maintenance : AQ-Testing (01 ❑ 3/5/ 18 Test i Maintenance: ❑ ❑ Test I Maintenance : ❑ ❑ Testi Maintenance: ❑ ❑ El 0 Testi Maintenance: Test / Maintenance: ❑ ❑ XI : FACILITY EMPLOYEE TRAINING Y N Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? ® ❑ E If the facility has more components then this form accommodates, additional copies of this page may be attached. Y = Yes, N = No, NA = Not Applicable, ID = Identification i i