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UNDERGROUND STORAGE TANK FDESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (page 2 of 2 F . MIN INSPECTION HISTORY w-up action of Section III from the previous inspection been completed appropriately? Y N Attach documentation vers ing appropriate service to this reportmom ❑x Vlll. ALARM HISTORY Attach a copy of the alarm historyre rOog to this re rt. Y N NA Is the monitoring system powered on and in properoperating mode? p ❑ ❑ Has each leak detection alarm since the previous Inspection been responded to appropriately? 11 ❑ Attach documentation ve in appropriate service to this re rt. 01 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 propersensor location. the results of the visual Inspection must be recorded in Section !X. IX. : UNDERGROUND STORAGE TANK SYSTEM INSPEC11ON Is the containment sump free of damage , water, debris and hazardous substance? Containment Sump ID Y N Containment Sump ID Y N 87 ❑ ❑ ❑ 91 a ❑ ❑ ❑ Diesel 0 ❑ ❑ ❑ 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 CI I ❑ Ffank ID 91 1 ❑x Q Tank ID IDIesel C] ❑ Tank ID ❑ ❑ Is the fill 1 e free of obstructions? Tank ID 187 D ❑ Tank ID 91 [i ❑ Tank ID IDiesel L7 ❑ Tank ID 1 ❑ ❑ Is the fill cap securely on the fillpipe? Tank ID 187 1911 ❑ 1 Tank ID 191 (M ❑ Tank ID 1131esel I 0 1 [31 Tank ID I ❑ ❑ Is the 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 Dispenser 1 /2 ❑ ❑ Dispenser 3/4 ® ❑ ❑ Dispenser 5/6 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? Q ❑ ❑ X. TESTING AND . MAINTENANCE Y N NA Date't ast Performed Has the monitoring system certification been completed within the past 12 months? Ci ❑ 1 /13/2020 Has the spill container testing been completed within the past 12 months? Ci ❑ 1 /13/2020 Has the overfill prevention equipment inspection been completed within the past 36 months? M ❑ ❑ 8/19/2019 Has the secondary containment testing been completed within the past 36 months? ® ❑ ❑ 8/27/2019 Has the tank tightness testing been completed within required timeframes? ❑ ❑ Has the line tightness testing been completed within the required timeframes? ❑ ❑ ❑x Other required testing i 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? Q ❑ I the facility has more components than this form accommodates, additional copies of this page may be attached. Y = Yes, N = W. NA = NotApplicable, ID = Identification i