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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 appropriate service to this report.) Ville 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? ® I] El Has each leak detection alarm since the previous inspection been responded to appropriately? ® ❑ 171(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 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,ro hazardous substance and er sensor location. The results of the visual inspection must be recorded in section IXIX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of damage, water, debris, and hazardous substance? Containment Sump ID Y VN Containment Sump IDY N RUL-Fill ® lRUL-STPowSum ® P Sum ® ❑ PUL-Fill ® ❑ ❑ PUL-STP-Sum ® ❑ ❑ Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? p 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 ® In DSL-Fill ® ❑ PUL-Fill ® ❑ N/A ❑ ❑ Is the fill cap securely on the fill pipe? TANK ID RUL-Fill ® ❑ DSL-Fell ® ❑ PUL- Fill ® ❑ N/A ❑ ❑ Is the under-dispenser containment free of damage, water, debris , and hazardous substance? Under-dispenser Containment ID Y I N N Aj Under-dispenser Containment ID Y N N Dispensers 1 -2 ® El ❑ ❑ p Dispensers 3-4 ® ❑ ❑ p ❑ Dispensers 5-6 ® ❑ ❑ ❑ p Dispensers 7-8 ® ❑ p p p Dispensers 9- 10 ® ❑ ❑ p p Dispensers 11 - 12 19101 ❑ 1 p ❑ Are all sensors In under-dispenser containment located to detect a leak at the earliest opportunity? ® ❑ p X. TESTING AND MAINTENANCE Y N NA LAST PEERFRF ORMED Has the monitoring system certification been completed within the past 12 months? ® ❑ 3/26/20 Has the spill container testing been completed within the past 12 months? ® ❑ 3/26/20 Has the overfill prevention equipment inspection been completed within the past 36 months? 0 El 171 3/25/ 19 Has the secondary containment testing been completed within the past 36 months? ® El p 3/5/13 Has the tank tightness testing been completed within required timeframes? ❑ ❑ ® PLLD Has the line tightness testing been completed within the required timeframes? ❑ 11 ® CSLD Other required testing / maintenance was completed within required timeframe. List test/maintenance items below. Test / Maintenance : AQ-Testing ® ❑ " 3/26/20 Test / Maintenance: Sections VI I thru XLL Continuous in tank leak detection method ® ❑ 9/24/20 Test / Maintenance: TLS-350 PLLD line testing See Alarm history report , * ® ❑ Test / Maintenance: FIMMP updated by Stantec Accepted ® ❑ 06/01 /20 Test / Maintenance: p ❑ Test / Maintenance: p p XI . FACILITY EMPLOYEE TRAINING Y N Have all individuals performing facility employee duties . received the required facility employee training within the past 12 months? I ® ❑ If the facility has more components than this form accommodates, additional copies of this page may be attached. Y = Yes, N = No, NA = Not Applicable, ID = Identification