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Underground StorageTan" PP7,.Ite T Operator Visual Inspection RepoSDed U of FOIL-W_UP ACTION Underground Storage Tank RIPTION appropriate compliance issues from Section Designated UST Operator Visual Inspection Report TOR UESC and to tNNENoPE�uP actions t, orri,ed by pp Will confirm espouse. 3 ). UST SYSTEM INSPECTION Nor„9-O�a uDc 14 921esPe� List below and In Section 3 all containment sumps that have had a release detection alarm 1.UD �ute'test. since the previous Designate-J$T OOperaalor inspection-Rcporl, have not been responded Z.was to by a qualified service technician. Containment sumps listed below require a visual Inspection for damage,water,debris,hazardous substance,and proper sensor location. Is the containment sump free of damage,water,debris,and hazardous substances? Containment Sump ID Yes No Containment Sump ID Yes No ❑ ❑ ❑ ❑ 13E313 ❑ Are all sensors in visually inspected containment sumps located to detect a release at 13 ❑ the earliest opportunity? Is the spill containment free of damage,water,debris,and hazardous substances?Is the fill pipe free of obstructions? Is fill cap securely on the rill pipe? Spill Containment ID Yes No Spill Containment ID Yes No 6. OWNER/OPERATOR ACKNOWLEDGEMENT OF INSPECTION RESULTS Spill Bucket-87S ® ❑ ❑ ❑ I have reviewed the results oft he designated UST operator inspection report an Spill Bucket-87N ® ❑ ❑ ❑ description of the action(s)taken or to be taken to correct any compliance issues gis�a Spill Bucket-91 Christian Torres 13 ❑ Name of UST Owner/Operator(print) UST Owner/Operator Signat re Date Signed 08/02/2023 ❑ ❑ ❑ Is the UDC free of damage, water,debris, and hazardous substances and all sensors located to detect a release at the earliest opportunity? ❑ No UDC(s)at this facility 7. INSPECTION HISTORY UDC ID Yes No UDC ID Yes Has each follow-up action of Section 3 from the previous Designated UST Yes Operator Inspection Report been completed appropriately? NO Dispenser-112 ® ❑ (Attach documentation verifying appropriate service to this report.) Dispenser-314 8. RELEASE DETECTION ALARM HISTORY ® ❑ Dispenser-516 � ❑ Attach a copy of the alarm history report/log to this report. Yes NO Dispenser-718 Is the monitoring system powered on and in proper operating mode? B 0 ❑ F13Q Has each alarm since the previous inspection been responded to appropriately? Dispenser-9110 0 ❑ (Attach documentation verifying appropriate service to this report.) ❑ 0 Dispenser-11112 0 ❑ Have all containment sumps, that have had an alarm since the previous ❑ ❑ designated UST operator inspection report, been responded to by a qualified service technician? ❑ j ❑ Mechanical float mechanisms used in UDCs. All answers marked WO"Must be described by the designated UST operator in Section 3. All answers marked"No"must be described by the designated UST operator in Section 3. Page P6 P HS-3081 dr:: HS- l7---iJO�fi - _ .. _