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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 111 from the previous inspection been completed appropriately? y N Attach documentation verifying appropriate service to this report F070 Vlll. ALARM HISTORY Attach a copy of the alarm history reporVIog to this report. Y N NA Is the monitoring system powered on and in proper operating mode? [] ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? documentation Keri in appropriate service to this report. ❑ ElAttach 7717EIT Have all containment sumps that have had a leak detection alarm since the previous inspection been responded to by a qualified UST Service Technician? El ❑ I 0101 first oeiow in section ut an conrammenr sumps Mat nave nau a ►eaK uetection 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 I Y I'N I Containment Sumn ID Y N Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? Y ❑ ❑ Is the spill container free of damage, water, debris, and hazardous substance? Has the monitoring system certification been completed within the past 12 months?[7 ❑ Tank ID 187 OCTANE p ❑ Tank ID 7717EIT ❑ ❑ Tank ID 191 OCTANE 0101 Tank ID DIESEL 2 1 Ell ❑ Is the fill i e free of obstructions? © ❑ ❑ 8/27/2019 Has the tank tightness testing been completed within required timeframes? Tank ID 187 OCTANE p ❑ 1 Tank ID ❑ 10 Tank ID 191 OCTANE B ❑ Tank ID DIESEL 2 ❑x ❑ Is the fill cap securely on the fill pipe? Tank ID 187 OCTANE [ ❑ Tank ID ❑ ❑ Tank ID 191 OCTANE IDIESEL 2 Is the under -dispenser containment free of damage, water, debris, and hazardous substance? p ❑ Under -Dispenser Containment ID Y N NA Under -Dispenser Containment ID Y N I NAI Dispenser 1/2 H1 ❑ ❑ Dispenser 3/4 01 ❑ Dispenser 5/6 0 ❑ ❑ ❑ ❑ ❑ Dispenser 9/10 M ❑ ❑ In n n Are all sensors in under -dispenser containment located to detect a leak at the earliest opportunity? f-xl n n X. TESTING AND MAINTENANCE Y N I NA Date Last Performed Has the monitoring system certification been completed within the past 12 months?[7 ❑ 1/13/2020 Has the spill container testing been completed within the past 12 months? O ❑ 1 /13/2020 Has the overfill prevention equipment inspection been completed within the past 36 months? C] ❑ ❑ 1/7/2019 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? ❑ ❑ 1 p Has the line tightness testing been completed within the required timeframes? ❑ ❑ R vtner requirea tesung i maintenance was Test / Maintenance: Test / Maintenance: Test / Maintenance: Test / Maintenance: Test / Maintenance: witnin required timeframe. (List test(maintenance items XI. FACILITY EMPLOYEE TRAINING Y N Have all Individuals performing facility employee duties received the required facility employee training within the past 12 months? [ ❑ 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