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illillillillillllllllIIIIIIIIIIIIII UNDERGROUND STORAGE TANK TANK OPERATOR VISUAL INSPECTION REPORT Pa e2 ERGROUND STODGE 702 DESIGNATED UNDVIIe INSPeECTION HISTORY otsection I ►► from the previous inspection been completed appropriately? Aa ch follow-up action Ing appropriate service to this report.Nas ea umentali°n verify VIII. ALARM HISTORY gdach d� °f the alarmh/storyreport/1°9 to this report.Adachoco s stem owered on and in ro er o eratin mode ?is the Onitorinch leak des ton alarm since the previous inspection been responded to appropriately?NBSadocumion vert n a ro r/ate service to this re ort.Have ailcotainment sumpsthat have had a leak detection alarm since the previous inspection been responded to bylified UST Service Technician ? ust below in Section IX all containment sumps that have had a leak detection alarm since the previous inspection and have not been responded to bya qualified UST Service Technician. Containment sumps listed below require a visual /nspect/on for damage, water, debris, harerdous substance and proper sensor location, The results of the visual inscrection must be recorded in Section 1X. 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 T -f = $� S l 6' 11 0 El Y N 1z : 5' t 3T- to ❑ EJ IZ , 1 < ic �. ❑ ❑ ❑ br El El 0 j Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? 12 ❑ Is the s III container free of damage , water, debris , and hazardous substance? " Tank ID 11 W g � ❑ Tank ID ❑ ❑ Tank ID s z . e) f , ❑ Tank ID ❑ ❑ Is the fill pipe free of obstructions? Tank ID e = g ❑ Tank ID ❑ ❑ I Tank ID z % St ❑ Tank ID ❑ ❑ Is the fill cap secively on the fill pipe? "dank ID — I ; Y ❑ Tank ID 01 ❑ Tank ID '� 2 ; P1 01 Tank ID 1 01 ❑ II Is the under-dis enseT containment free of dama e , water, debris , and hazardous substance? Under-011nser Containment ID Y N NA Under•Dispenser Containment ID I Y I N I N 44 Dispenser 112 ❑ ❑ Dispenser 3/4 10 1 ❑ 111 Dispenser 5/6 EQ4 ❑ ❑ Dispenser 7/8 101 ❑ ❑ Dispenser 9/10 ❑ ❑ Dis enser 11 / 12 01 ❑ I ❑ ❑ ❑ ❑ 1:11 ❑ it - - - ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? NJ ❑ ❑ X. TESTING AND MAINTENANCE Y FN FNA Date Last Performed Has the monitoring system certification been completed within the past 12 months? ❑ ❑ 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? El ❑ pg xyH r'1 Has the tank tightness testing been completed within required timeframes? ❑ ❑ 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: _ _ _ Cl ❑ Test / Maintenance : _— ❑ El Test ! Maintenance _ _- _ ❑ ❑ Test / Maintenance: ------ - Test ----- -Test / Maintenance: __ 01 ❑ Test / Maintenance: 101 ❑ Xi . FACILITY EMPLOYEE TRAINING Y N Have 811 individuals performing facility employee duties received life required facility employee training within the past 12 months? �1 ❑ / the facility has mare components than this form accommodates, additional copies of this page may be attached. Y = Yes. N = hb, NA = Not AppkaW ID = klertimbW