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L. lIL f ; AillillL UNDERGROUND STORAGE TANK - - . UNDERGROUND So FORAGE TANK OPERATOR VISUAL INSPECTION REPORT g 2e 2 oT 2.11 VII . INSPECTION HISTORY Y N as each follow- up action of Section III from the previous inspection been completed appropriately? ❑ this reports Attach documentation verifying appropriate service to VIII. ALARM HISTORY Y N NA Attach a copy of the alarm historyre ort/log to tills reports ❑ ❑ Is the monitoring system powered on and In roper operating mode ? ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? Attach documentation verif In appropriate service to this re ort. ave all containment sumps that have had a leak detection alarm since the previous Inspection been responded to by a ❑ El alified UST Service Technician? st below in Section IX all containment sumps (fiat have had a leak detection alarm since the previous inspection and have not been aponded to by a qualified UST Service Technician. Containment sumps listed below require a visual Inspection for damage, water, debris, rdous substance and ro er sensor location, The results of the visual Inspection must be recorded in Section iX. IX. UNDERGROUND STORAGE TANK SYSTEM INSPECTION e contalnment sump free of damage , water, debris , and hazardous substance? Containment Sump ID Y N Containment Sump ID Y N ❑ ❑ ❑ ❑ El 0 ---- - -- ❑ ❑ ❑ ❑ 0 01 El 0 all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? ❑ ❑ e s III container free a of damage, water, debris , and hazardous substance? 1 kIDI TI Q ❑ Tank ID T Z = I ❑ k ID ❑ ❑ Tank ID ❑ ❑ e fill pipe free of obstructions? Is ID T i : 3 �- ❑ Tank ID _ k ID ❑ ❑ TanklD ❑ e fill cap securely on the fillpipe ? — — Adlll� mod" El ID 1 2 : �� t El ❑ Tank ID El +/ e under-dispenser containment free of dama e , water, debris , and hazardous substance ? ❑ ❑ Under•Dispenser Containment ID Y N NA Under-Dispenser Containment ID Y N N Dis enser 1 /2 11 ❑ ❑ Dispenser 3/4 _ ElDis enser 5/6 I) El ElDispenser 7/8 ❑ ❑ Dis enser 9/ 10 ❑ ❑ Dispenser 11 / 12 ❑ El El ❑ i ❑ O ❑ - - ❑ [1 [1 ment located to detect a leak at the earliest opportunity Are all sensors in under-dispenser contain ? ❑ Ell Ei ❑ ❑ X. TESTING AND MAINTENANCE Y N NA Date Last Has the monitoring system certification been completed within the past 12 months El - 1 -1Performed j Has the spill Container testing been completed within the past 12 months? — Has the overfill prevention eyuipment inspection been completed within the past 36 months? ❑ El Has the secondary containment testing been completed within the past 36 months ? ❑ El ❑ _ z ElHas the tank tightness testing been completed within required timeframes? ❑ �' � Has the line tightness testing been completed within the required timeframes? ❑ ❑ Other required test;ng i maintenance was completed within required timeframe . (List test/maintenance /tams lbe I Test ; Maintenance : Test / 1Maintenance :Test i MaintenanceTest 1 Maintenan Test / Maintenance:Test / Maintenance: -Xi. FACILITY Ei' acre all individuals performing facility em to EMPLOYEE TRAINING Y N p Yew duties received the required facility e e facility has more components than this fa,Tn accom— 'moda�es additional copies of this y ae a mtraining be attached past 12 months? � - - Yes, N = i o, NA = No Appl , Ip = Ids p g Y