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• UlNbERGROUND 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. VIII. ALARM HISTORY Y N NA Attach a copy of the alarm history report/log to this report ❑ ❑ is the monitoring s stem owered on and in ro er o eratin mode? Has each leak d_teCion aiarm since the previous inspection been responded to appropriately? ❑ ❑ Attach documentation ve fyinq 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 ualified UST Service Technician? List below in Section IX all containment sumps that have had a leak detection alarm since the previous tion for da and have not been responded to by a qualified UST Service Technician.Containment sumps listed below require a visual inspection for damage,wafer,debris, hazardous substance,and propersensor location. The results of the visual ins ection 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 Sum ID Y N Containment Sum ID ❑ [; ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ [01 ❑ Arc all sensors in containment sumps inspected located to detecta i a at the earliest opportunity? ❑ Is the spill container free of damage,water,debris,and hazardous substance? ❑ Tank ID ❑ TanklD I ❑ ❑ Tank ID j ❑ TanklD Is the fill i e free of obstructions? ❑ Tank ID ✓ ❑ Tank ID ❑ Tank ID ` E] Tank ID Is the fill cap securely on the fill pipe? ❑ Tank ID ' ❑ TanklD El Tank ID Tank ID ❑ Is the under-dispenser containment free of damage.water,debris.and hazardous substance? Under-Dispenser Containment ID Y N NA Under-Dispenser Containment ID Y D Dis enser 1i2 1,0,1 ❑ ❑ Dis enser 314 ❑ ,❑ Dis enser 516 ❑ ❑ ❑ Cis enser 7/8 [ . ❑ El Dis enser 11/12 r ❑ Dispenser 9/10 ❑ 11 ❑ ❑ b El HT1: — ❑'' ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? 0 El X. TESTING AND MAINTENANCE Y N NA' Date LastPerformed Has the monitoring system certification been completed within the past 12 months? ❑ ❑ 11/21/2018 Has the spill container testing been completed within the past 12 months? ❑ ❑ - 11121/2018, Has the overfill prevention equipment inspection been completed within the past 36 months? El El ❑ t Has the secondary containment testing been completed within the past 36 months? ❑ ❑ L1 -_ n Has the tank tightness testing been completed within required timeframes? ❑ J Has the line tightness testing been completed within the required timeframes? ❑ ❑ Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) Test/Maintenance:Vapor Recovery ❑ ❑ 10/13/2018 Test/Maintenance:Bi-Annual V/L's _ ❑ 41113/2018 Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ Test?Maintenance: J ❑ Test 1 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? ❑ I the facility has more components than this form accommodates,additional copies of this page may be attached. Y=Yes,N =No NA=Not Apdicable,IC=Identification