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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 N Attach documentation verifying appropriate service to this report. ❑ Vlll . ALARM HISTORY Attach a copy of the alarm history report/log to this report. Y N NA Is the monitoring system powered on and in proper operating mode? 19 ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ❑ ❑ Attach documentation veqWpg 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 proper sensor location. The results of the visual inspection must be recorded in Section IX. IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of damage , water, debris , and hazardous substance? Containment Sump ID Y N Containment Sump 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 I F 7 1 M1 ❑ TanklD ❑ ❑ Tank ID Liz ❑ 1 Tank ID ❑ ❑ Is the fill pipe free of obstructions? Tank ID 7 ❑ Tank ID I 01 ❑ Tank ID / 01 Tank ID ❑ ❑ Is the fill cap securely on the fill pipe? Tank ID 1 .97 01 Tank ID 1 ❑ ❑ Tank ID W1 ❑ anID [I ❑ Is the under-dispenser containment free of damage , water, debris , and hazardous substance? Under-Dispenser Containment ID Y I N INAI Under-Dispenser Containment ID Y N NA Dispenser 1 /2 ❑ ❑ Dispenser 3/4 ❑ ❑ Dispenser 5/6 ❑ ❑ M Dispenser 7/8 ❑ ❑ Dispenser 9/10 ❑ ❑ J 9 Dispenser 11 /12 ❑ ❑ ❑ ❑ 13 El ❑ ❑ 171 El❑ ❑ 1:1 11 )9 Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? El X. TESTING AND MAINTENANCE YLN NA Date LastPerformed Has the monitoring system certification been completed within the past 12 months? lfm/yam /Has the spill container testing been completed within the past 12 months?Has the overfill prevention equipment inspection been completed within the past 36 months? ❑ ❑ Has the secondary containment testing been completed within the past 36 months? ❑ ❑ 9 2y I Has the tank tightness testing been completed within required timeframes? ❑ IR ❑ Has the line tightness testing been completed within the required timeframes? ❑ ❑ Other required testing / maintenance was completed within required timeframe. (List test/maintenance items below.) Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test ! Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / 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? El 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, ID = Identification UN -111 www.unidocs .org 2/2 - Rev. 06/14118 i