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MOJNDERGROUND STO-fi ft, <br />DESIGNATED UNDERGROUND ST'ORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 2 of 2) I <br />VII. INSPECTION HISTORY Y N <br />Has each follow-up action of section III from the previous inspection been completed appropriately? <br />(Attach documentation verifying appropriate service to this report.) El 0 <br />VIII. ALARM HISTORY <br />Attach a copy of the alarm history report/log to this report. Y N NA <br />Is the monitoring system powered on and in proper operating mode? a 0 0 <br />Has each leak detection alarm since the previous inspection been responded to appropriately? <br />(Attach documentation verifying appropriate service to this report.) El El El <br />Have all containment sumps, that have had a leak detection alarm since the previous inspection, been responded to by a qualified UST <br />service technician? <br />• • rz <br />List below in section IX, all containment sumps that have had a leak detection alarm since the previous inspection and have not been <br />responded to by a qualified UST service technician. Containment sumps listed below require a visual inspection for damage, water, debris, <br />hazardous substance, and proper sensor location. The results of the visual inspection must be recorded in section IX. <br />IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION <br />Is the containment sump free of damage, water, debris, and hazardous substance? <br />Containment Sump ID Y N Containment Sump ID Y N <br />Sump 1 ElLI 0 0 <br />Sump 2 rLJ LID <br />s 0 • 0 <br />0 LID <br />Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? N 0 <br />Is the spill container free of damage, water, debris, and hazardous substance? <br />TANK ID Tank 1 0 LIE] <br />ID El <br />I <br />0 0 <br />Is the fill pipe free of obstructions? <br />TANK ID Tank 1 • 0 <br />LI O I 0E 0 <br />Is the fill cap securely on the fill pipe? <br />TANK ID Tank 1 Q D ULi <br />• El LI D <br />Is the under-dispenser containment free of damage, water, debris, and hazardous substance? <br />Under-dispenser Containment ID Y N NA Under-dispenser Containment ID Y N NA <br />Dispenser 1 r • • LI 0 0 <br />0 • 1-1 0 0 0 <br />• U. • • • <br />0 0 0 DD E] <br />UDU • [I <br />0 0 • 0 0 0 <br />Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? LI MI <br />TESTING AND MAINTENANCE Y N NA DATE LAST <br />PERFORMED <br />Has the monitoring system certification been completed within the past 12 months? III <br />:',0--'. 76aat <br />11/20/19 <br />11/20/19 Has the spill container testing been completed within the past 12 months? - • <br />Has the overfill prevention equipment inspection been completed within the past 36 months? • • • 11/08/18 <br />Has the secondary containment testing been completed within the past 36 months? - 1:1 0 11/08/18 <br />Has the tank tightness testing been completed within required timeframes? 0 • <br />Has the line tightness testing been completed within the required timeframes? • El <br />Other required testing! maintenance was completed within required timeframe. (List tesUmaintenance items below.) <br />jest / Maintenanclkaar boot replaced .4 0 12/23/19 <br />Test / Maintenance: U 0 <br />Test! Maintenance: El El <br />Test / Maintenance: • 0 <br />Test / Maintenance: • 0 <br />Test / Maintenance: El 0 <br />FACILITY EMPLOYEE TRAINING Y N <br />Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? 0 0 <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />V = Vpc N = Nn Nt = Annlirahlp in = lehantifiratinn