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�r UNDERGROUND STORAGE TANK DF%GNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT tPage VII, INSPECTION HISTORY 2012) Nas�documentation n of Section III from the previous inspection been completed appropriately? Attarifying appropriate service to this report- Y N tom, Vlll. ALARM HISTORY ® ❑ Attach a copy of the alarm histo report/log to this report. Y N NA Is the monitoring system powered on and in roper OP ratingemode? ® ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ❑ ❑ Attach documentation veritying 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 sums 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 ro er 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? Contalnment Sum ID Y N Containment Sump ID Y N ❑ ❑ ❑ ❑ ❑ a 10 _❑ ❑ 01 ❑ ❑ ❑Are alt sensors in containment sumps inspected located to detecta leak at the earliest opportunity? ❑ ❑ Is the spill container free of damage,water, debris,and hazardous substance? Tank ID Spilt Bucket-87 EAST Tank ID Is Bucket-8T WEST ❑ Tank ID Spill-Bucket_91 �) ❑ Is the fill pipe free of obstructions? ❑ Tank ID Spill Bucket-Additive SCJ ❑ Tank ID SpiiT Bucket=8TE Tank ID p ❑ Tank ID piffBucke- ❑ Spill Bucket-87 WEST ® ❑ Tank ID Spill Bucket-Additive Is the fitl cap securely on____Ihe fii pipet ® ❑ Tank ID Spill Bucket-87 EAST ® ❑ Tank ID Spill Bucket-91 ❑ Tank ID Spill Bucket-87 WEST IN C3 Tank ID Spill Bucket-Additive T Is the under-dispenser containment free of damage, water,debris,and hazardous substance? ❑ Under-Dispenser Containment ID Y N NA tSperlser- Under-Dispenser Containment ID Y N N Dispenser-3/4 ® ❑ ❑ Is—pe nse�=1 /14 ® ❑ ❑ tspen—se r-6 6d ❑ ❑ Dispenser-15/16 Q9 ❑ ❑ ❑ O FS pense�--7'[S CK ❑ 0 ❑ ❑ ❑ Dispenser-9%10 ® ❑ p ❑ bispenser-1 12 ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ ❑ ❑ ® Cl ❑ X. TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? l- ❑ ozo Vi Has the spill container testing been completed within the past 12 months? ❑ _ _ _ _ Illq Has the overfill prevention equipment inspection been completed within the past 36 months? x ❑ ❑ 05/21/2019 Has the secondary containment testing been completed within the past 36 months? ❑ ❑ 9 N/A W�a,f Has the tank tightness testing been completed within required timeframes? ❑ ❑ ® N/A Has the line tightness testing been completed within the required timeframes? 0101 ® N/A Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ XI. FACILITY EMPLOYEE TRAINING Y IN Nave all individuals performing facility employee duties received the required facility employee training within the past 12 months? ❑ 1 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 COSTCO-1091 -0412312020