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UNDERGROUND STORAGE TANK DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 2 of 2) VII. INSPECTION HISTORY Has each follow-up action of Section III from the previous inspection been completed appropriately? Y I N Attach documentation verifying appropriate service to this report. ® ❑ VIII. . ALARM HISTORY Attach a copy of the alarm histo report/fogreportliog to this report. Y N NA Is the monitoring system powered on and in proper operating mode? ® ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? 50 ❑ ❑ 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 amper sensor location. The results of the visual ins tion must be recorded in Section 1X. IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION is the containment sump free of damage, water, debris,and hazardous substance? Containment Sump ID Y N Containment Sum ID Y N ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 Sill Bucket-87 f$ ❑ Tank ID I Spill Bucket-DIESEL �I ❑ Tank ID $ ill Bucket-91 01 Tank ID I I ❑I ❑ Is the fill pipe free of obstructions? Tank ID tipill BUc e ❑ Tank ID Spill Bucket-DIESEL ❑ Tank ID Spill Bucket-91 I ®1 01 Tank ID 01 ❑ Is the fill cap securely on the fill pipe? Tank ID Spill Bucket-87 21 01 Tank ID Spill Bucket-DIESEL ❑ Tank ID Spill Bucket-91 091 ❑ I Tank ID ❑ ❑ Is the under-dispenser containment free of damac e, water,debris, and hazardous substance? Under-Dispenser Containment ID Y N I NAI Under-Dispenser Containment ID Y N N Dispenser-172 N1 ❑ ❑ ❑ ❑ ❑ Dispenser-3l4 Id ❑ ❑ ❑ ❑ ❑ Dispenser-5/113 99 ❑ ❑ ❑ ❑ ❑ Dispenser-7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ® ❑ ❑ X. TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? 29 ❑ 216120 Has the spill container testing been completed within the past 12 months? pg ❑ 216120 Has the overfill prevention equipment inspection been completed within the past 36 months? N ❑ ❑ 3113119 Has the secondary containment testing been completed within the past 36 months? ® ❑ ❑ 8/5120 Has the tank tightness testing been completed within required timeframes? ❑ ❑ ® NIA Has the line tightness testing been completed within the required timeframes? ❑ ❑ ® WA Other required testing/maintenance was completed within required timeframe. (List test/maintenance items below.) Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test 1 Maintenance: ❑ ❑ Test I Maintenance: 1 01 ❑ XI. FACILITY EMPLOYEE TRAINING Y N Have 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,10=Identification 7-11 -35355-08/11/2020