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M cn -0q) Z-- CD = � < CD O rn o --1o � N OCD N O O �l UNDERGROUND STORAGE TANK M = ot DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT[P=2af W VII. INSPECTION HISTORY Y N z Has each follow-up action of Section III from the previous inspection been completed appropnately' ® ❑ C Attach documentation verifying appropriate service to this report. — Vlil. ALARM HISTORY y lr NA fn OA Attach a co of the alarm histo nP ort/lo to this ort ® ❑ ❑ Is the mor in s stem owered on and in to er o eratin modes C Has each leak detection alamn since the previous inspection been responded to appropratell`? ❑ ❑ air Attach documentation verifying appropriate service to this re ort. Have all containment sumps that have had a leak detection alarm since the previous inspection been responded to by a ualified UST Service Technician? W List below in Section lX all containment sumps that have had a leak detection alarm slice the Previous insp inspectionforda and,w not been responded to by a qualified UST Service Technklan.containment sumps listed below require a visual inspecLon for damage,water,d O hazardous substance,and ersensorlocadon. The results of the visual Inspection must be recorded in section TX. n IX. UNDERGROUND STORAGE.TANK SYSTEM INSPECTION � _ O 15 the containment sump free of damage,water,debris, nd hazardous substance? Y N Z3 Containment Sum ID Y aN Containment sum 10 ❑ 13 _ 87 OCTANE STP ❑x ❑ ❑ ❑ D 91 OCTANE STE O -EI ❑ ❑ 5 El 01 ❑ ❑ N Are all sensors in containment sumps inspected located to detectlea ❑ k at the earliest opportunity? ❑ Is the spill container free of damage,water,debris,and hazardous substance? Tank 10 87 [ITanklD ❑ ❑ Tank 10 91 ><❑1 ❑1 Tank l0 1 01 ❑ is the fill pipe free of obstructions? Tank ID 187 p ❑ Tank ID 1 01 ❑ Tank I0 191 121 ❑ Tank ID 1 01 ❑ Is the fill ea -securely an the fill pipe? Tank ID 87 O 1 ❑ Tank ID ❑ ❑ Tank ID 191 D ❑ Tank ID 01 ❑ Is the under-dispenser containment free of dame e,water,debris,and hazardous substance? Under-Dispenser Containment IDY UndeUnder-DispenserContainment ID Y N NA Dispenser 112 p ❑N NA❑ Dis enser 314 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ ❑ ❑ X. TESTING AND MAINTENANCE Y N NA Dante Last TO Has the monitoring system certification been completed vdthin the past 12 months? P Has the spill container testing been completed within the past 12 months? ® ❑ 616MI9 r Has the ove�il prevention equipment inspection been completed"I the past 36 months? IR ❑ 616ft9 Has the secondary containment testing been completed within the past 36 months? ® ❑ _g_ 12111/18 Has the tank tightness testing been completed within required timeframe s? ® ❑ 1:1zrena Has the line tightness testing been completed within the required timeframes? ❑ Other required testing!maintenance was completed within required timeme. is tesUrri8intenance items beaotr! Test/Maintenance: fra � Test/Maintenance: C)❑ ❑ C) O Test/Maintenance: ❑ 13 (Z CD Test/Maintenance:ce: 13 ❑ D O Q Test/Maintenan13 ❑ I Test/Maintenance: ❑ ❑ XI, FACILITY EMPLOYE © W Have all individuals performing facility employee duties received the required fa cilE TRAINING 1 the facility has more components than this form accommodates,additional copies of thlls yee train4n Y � g within the past 12 tttpttiytyp N Y=Yes,N=No,NA=Not paQe may be attached. ® ❑ W CD Applicable,ID=Iden6fi a on W N � O O N