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UNDERGROUND STORAGE TANK PDDESIGNATED;IUNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Page 2 of 2) VII. INSPECTION HISTORY aseach follow-up action of Section III from the previous inspection been completed appropriately? N Attach documentation verifying appropriate service to this report. 0 ❑ VIII. ALARM HISTORY Attach a copy of the alarm histo re ort/lo Y N NA to this report- ❑ ❑ Is the monitonn system powered on and in proper operatingmode? 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 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 inspection must be recorded in Section IX. IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of damage.water, debris, and hazardous substance? Y N Containment Sum ID Y N Containment Sum ID ❑ ❑ ❑ ❑ ❑ ❑ 1`7 ❑ �/ ❑ ❑ _/ ❑ ❑ [0] ElEl ❑ Are all sensors in containment sumps inspected locatec to detect a leak at the earliest opportunity? ❑ ❑ Is the spill container free of damage,water. debris, and hazardous substance? ❑ Tank ID ❑i Tank ID Tank ID ❑ Tank ID ❑ ❑ Is the fill pipe free of obstructions? ElTank ID Q" ❑ Tank ID ❑ ❑ Tank ID I ❑ Tank ID Is the fill ca urely on the fill pipe? El kID El Tank ID Tank ID ❑ Tank ID ❑ F1 Is the under-dispenser containment free of damage,water,debris, and hazardous s substance? enser Containment ID Y, N NA Under-Dispenser Containment ID Y N NA P [1 ❑ Dispenser 1/2 ❑ ❑ Dis enser 3/4 ❑ ❑ Dispenser 5/6 Gl El enser 718 [] ❑ ❑ Dispenser 11/12 El ❑ Dispenser 9/10 ❑ El D ❑ ❑ 11 ❑ [1[I El ET ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? Y N NA Date Last X. TESTING AND MAINTENANCE Performed 11/18/2019 Has the monitoring system certification been completed within the past 12 months? ❑ 11/18/2019 Has the spill container testing been completed within the past 12 months? Has the overfill prevention equipment inspection been completed within the past 36 months? ❑ Has the secondary containment testing been completed within the past 36 months? U 0 LX-1Has the tank tightness testing been completed within required timeframes? El Has the line tightness testing been completed within the required timeframes? ❑ ❑ Other required testing/maintenance was completed within required timeframe. (List testlmaintenance items . 10/7/2019 Test/Maintenance:Va or ReCove ❑ ❑ " 1 4/13/2018 Test/Maintenance:Bi-Annual V/L's ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: Y N XI. FACILITY EMPLOYEE TRAINING Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? El I the facility has more components than this form accommodates,additional copies of this page may be attached. Y=Yes,N =No,NA=Not Applicable.10=Identification