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UNDERGROUND STORAGE TANK FDESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT ( Page 2 of 2) VII. 'INSPECTION HISTORY w-up action of Section ill from the previous inspection been completed appropriately? Y N Attach documentation verifying appropriate service to this report. ❑ ❑ Vill. ALARM HISTORY Attach a copy of the alarm histo LeMrVlog to this report, Y N NA Is the monitoring system powered on and in proper operating mode? ❑p ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ❑ ❑ lZ Attach documentation X!ylylng 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 propersensorlocat/on. The results of the visual Inspection must be recorded in Section /X. IX. . UNDERGROUND STORAGE TANK SYSTEM INSPECTION Is the containment sump free of damage , water, debris, and hazardous substance? Containment Sum ID Y 'N Containment Sum ID Y . N ❑ ❑ ❑ ❑ ❑ ❑ D ❑ 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 187 OCTANE 1 [9 ❑ Tank ID ❑ p Tank ID 191 OCTANE 1 [91101 Tank ID DIESEL 2 x❑ ❑ Is the fill pipe free of obstructions? Tank ID 187 OCTANE Ci D Tank ID ❑ ❑ Tank ID 191 OCTANE I Cxl 10 1 Tank ID IDIESEL 2 0 111 Is the fill cap securely on the fill pipe? Tank ID 187 OCTANE M1 01 Tank ID 1 ❑ ❑ Tank ID 191 OCTANE © 10 1 Tank ID IDIESEL 2 t7 ❑ Is the under-dispenser containment free of damage, water, debris, and hazardous substance? Under-DIs enser Containment ID Y N I NAI Under-Dispenser Containment ID Y N N Dispenser 1 /2 Cl ❑ ❑ 1 Dispenser 3/4 ® ❑ ❑ Dispenser 5/6 ® ❑ 01 ❑ ❑ Dispenser 9/10 Cl ❑ ❑ ❑ ❑ ❑ ❑ !ot11 El 1:1D ❑11 11 01 ❑ ❑ Are all sensors in under-dis ser containment located to detect a leak at the earliest opportunity? Ri ❑ 1 0 X. TESTING AND MAINTENANCE - Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? R7 ❑ 1 /13/2020 Has the spill container testing been completed within the past 12 months? O D 1 /13/2020 Has the overfill prevention equipment inspection been completed within the past 36 months? 1 /7/2019 Has the secondary containment testing been completed within the past 36 months? ® ❑ ❑ 8/27/2019 i 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: O ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Testi Maintenance : ❑ ❑ Xis FACILITY EMPLOYEE TRAINING Y N Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? p ❑ 1 the facility has more components than this form accommodates, additional copies of this page may be attached. Y = Yes, N = No, NA = Not Appicable, ID = identification i I