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UNDERGROUND STORAGE TANK UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 2 of 2) FDESIGNATED VII. INSPECTION HISTORY ow -up action of Section III from the previous inspection been completed appropriately? Attach documentation verifying appropriate service to this report. Y N El Vill. ALARM HISTORY Attach a copy of the alarm history reporVlog to this re ort. Y N NA Is the monitorings stem powered on and in proper operating mode? p ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? documentation ver in a ro riate service to this report. 11 E -]Attach Have all containment sumps that have had a leak detection alarm since the previous inspection been responded to by a qualified UST Service Technician? 11 List below in Section /X all containment sumps that have had a leak detection alarm since the previous Inspection and have not been responded to by a qualified UST Servlce 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 INSPECTION Is the containment sump free of damage, water, debris, and hazardous substance? Containment Sump ID Y N I Containment Sump ID Y N 87 p 01 ❑ ❑ 91 1E ❑ ❑ ❑ Diesel 0 ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in containment sumps inspected located to detect a leak at the earliest opportunity? El [] Is the spill container free of damage, water, debris, and hazardous substance? Tank ID 187 CI ❑ Tank ID 91 1] ❑ Tank ID Diesel L7 1 ❑ 1 Tank ID ❑ ❑ Is the fill i e free of obstructions? Tank ID 187 ff] I ❑ I Tank ID 191 ❑x 0 Tank ID I Diesel p ❑ Tank ID —111-0 Is the fill cap securely on the fill pipe? Tank ID 187 El I ❑ I Tank ID 191 p ❑ Tank ID IlDiesel I Ell ❑ 1 Tank ID I ❑ 13 Is the under -dispenser containment free of damac, e, water, debris, and hazardous substance? Under -Dispenser Containment ID Y N NAI Under -Dispenser Containment ID Y N N Dispenser 1/2 0 ❑ ❑ Dispenser 3/4 ® ❑ ❑ Dispenser 5/6 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ell ❑ ❑ ❑ ❑ ❑ 01 ❑ ❑ 01 01 ❑ 1711 ❑ Are all sensors in under -dispenser containment located to detect a leak at the earliest opportunity? I] ❑ ❑ X. TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? 9 ❑ 1/13/2020 1/13/2020 Has the spill container testing been completed within the past 12 months? 19 ❑ Has the overfill prevention equipment inspection been completed within the past 36 months? 19 ❑ ❑ 8/19/2019 Has the secondary containment testing been completed within the past 36 months? 2 ❑ ❑ 8/27/2019 Has the tank tightness testing been completed within required timeframes? ❑ ❑ p Has the line tightness testing been completed within the required timeframes? ❑ ❑ [j Other required testing / maintenance was completed within required timeframe. (List test(maintenance items below.) Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: ❑ ❑ Test / Maintenance: p ❑ Test / Maintenance: 01 El XI. FACILITY EMPLOYEE TRAINING JY N Have all individuals performing facility employee duties received the required facility employee training within the past 12 months? R ❑ 1 "Ja iacnhy has mury cunepuncros roan mrs rorm accommoaares, aaa monat copies of this page may oe attacnetl. Y = Yes, N = No, NA = Not Applicable, 10 = Identification