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�r <br />UNDERGROUND STORAGE TANK <br />DESIGNATED UNDERGROUND STORAGE I NSPEUr- ONHISTORY <br />K V1511.11 <br />1 uAL INSPECTION REPORT Wage 2 of <br />"as each follow-up action of Section 111 from the previous inspection been completed appropriately? <br />Attach documentation verifying appropriate service to this rePL�RMSTORY <br />rtY <br />VIII, <br />Attach a copy of the alarm history report/log to this report. Y fN4,4 <br />Is the monitorin s stem owered on and in ropero eratin mode? ® Has each leak detection alarm since the previous inspection been responded to appropriately? Attach documentation verservice to this report. <br />Have all containment sumps that have had a leak detection alarm since the previous inspection been responded to by a <br />-qualified UST Service Technician? <br />List below In Section IX all containment sums 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 I Y I N F Containment Sump ID Y N <br />Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? <br />Is the spill container free of damage, water, debris, and hazardous substance? <br />Tank 1D Spill Bucket -87 EAST <br />Tank ID Spill Bucket -8T WEST O Tank ID Spill-Bucl <br />Is the fill pipe free of obstructions? LD Tank ID Spill Buc) <br />Tank ID SpiiT Bucket=8TEAS1--- <br />Tank ID Spill Bucket -87 WEST <br />Is the fill cap securely on____�he f�i pipes <br />Tank ID Spill Bucket -87 EAST <br />Tank ID Spill Bucket -87 WEST <br />Is the under -dispenser containment free of <br />Under -Dispenser Containment ID <br />uispenser-3/4 <br />-Dispen-se r -S/6-- <br />DFspense_r-7'/S <br />Dispenser -9h 0 <br />Dispenser -1 12 <br />Are all sensors in under-dis <br />Has the monitoring sy <br />Has the spill container <br />Has the overfill preve <br />Has the secondary co <br />Has the tank tightness <br />Has the line tightness <br />Other required testing <br />Test / Maintenance <br />Test / Maintenance <br />Test / Maintenance <br />Test / Maintenance <br />Test / Maintenance <br />Test / Maintenance <br />dditive <br />Tank ID ,Pill tfucKet-91 <br />Tank ID I Spill Bucket -Additive <br />Tank ID Spill Bucket -91 <br />Tank ID Spill Bucket -Additive <br />and hazardous substance? <br />Under -Dispenser Containment ID <br />IDspenser=1$/14 <br />Dispenser -15/16 <br />nser containment located to detect a leak at the earliest <br />X. TESTING AND MAINTENANCE <br />stem certification been completed within the past 12 months? <br />testing been completed within the past 12 months? <br />ntion equipment inspection been completed within the past 36 months? <br />ntainment testing been completed within the past 36 months? <br />testing been completed within required timeframes? <br />testing been completed within the required timeframes? <br />/ maintenance was completed within required timeframe. (List test/maintenance items <br />JC <br />WVQ <br />Y I N NA I Date Last <br />!05/21/2019 <br />0 <br />/A 4"4f <br />N/A 3 ZA . <br />I XI. FACILITY EMPLOYEE TRAINING I Y I N I <br />Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? I �' ❑, <br />1 the facility has more components than this form accommodates, additional copies of this page may be attached. <br />Y = Yes, N = No, NA = Not Applicable, ID = Identification <br />COSTCO - 1091 - 0412312020 <br />