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UNDERGROUND STORAGE TANK FDESIGNAITED UNDERGROUND STORAGE TANK OPERATOR VISUAL. INSPECTION REPORT(Page 2 of 2) VII. INSPECTION HISTORY w-up action of Section III from the previous inspection been completed appropriately? Y I N Attach documentation verifying appropriate service to this report $j ❑ VIII. ALARM HISTORY Attach a copy o1 the alarm history reportliog 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? JO ❑ ❑ 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 aff 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 ins tion must be recorded in Section IX. IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of dams e,water, debris,and hazardous substance? Containment Sump ID Y j N Containment SuTR ID Y N ❑ 13 [1 Cl ❑ ❑ 11 ❑ ❑ 11 El ❑ ❑ ❑ ❑ ❑ 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 Spill Bucket-87 C9 I [11.Tank ID Spill Bucket-DIESEL ki ❑ Tank ID Spill Bucket-91 ❑ Tank ID El Is the fill pipe free of obstructions? Tank ID Spill ffucket-157 Tank ID Pt uc e - SEL ❑ Tank ID Spill Bucket-91 IN ❑ Tank ID ❑ ❑ Is the fill cap securely on the fill pipe? Tank ID Spill Bucket-87 ® ❑ Tank ID Spill Bucket-DIESELEl Tank ID Spill Bucket-91 C1 I ❑ I Tank It] 1 ❑ ❑ Is the under-dispenser containment free of damaC e,water,debris,and hazardous substance? Under-Dispenser Containment ID Y I N INAI Under-Dispenser Containment ID Y N N Dispenser- IM ❑ ❑ ❑ ❑ ❑ Dispenser-314 6d ❑ ❑ ❑ ❑ ❑ Dispenser-5/6 99 ❑ ❑ ❑ ❑ ❑ Dispenser-7/8 is ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ =[] -D ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? El ❑ ❑ X. TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? ❑ 216120 Has the spill container testing been completed within the past 12 months? 216120 Has the overfill prevention equipment inspection been completed within the past 36 months? N ❑ ❑ 311311g Has the secondary containment testing been completed within the past 36 months? ® ❑ ❑ 815120 Has the tank tightness testing been completed within required timeframes? ❑ ❑ ® NIA Has the line tightness testing been completed within the required timeframes? ❑ ❑ ® NIA Other required testing l maintenance was completed within required timeframe. (List test/maintenance items below.) Test i Maintenance: ❑ ❑ Test 1 Maintenance: C1 ❑ Test 1 Maintenance: ❑ ❑ Test/Maintenance: ❑ ❑ Test 1 Maintenance: ❑ ❑ 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 Applicable,10=Identification 7-11 -35355-09/04/2020