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UNDERGROUND STORAGE TANK DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT ( Page 2of 2) VII . INSPECTION HISTORY Has each follow- up action of Section III from the previous inspection been completed appropriately? Y N Attach documentation verifying appropriate service to this report. ® ❑ VIII . ALARM HISTORY Attach a copy of the alarm history report/logreportliog to this report. Y N INA Is the monitoring system powered on and in proper operating mode? ® ❑ 1 ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ® ❑ ❑ Attach documentation verifying 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 ® ❑ ❑ gualified 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 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 Y N Containment Sump ID Y N ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 00 1 /Diesel /6 , 000gal ® ❑ Tank ID ❑ ❑ Tank ID ❑ ❑ TankID ❑ ❑ Is the fill pipe free of obstructions ? Tank ID 001 / Diesel /6 , 000gal ® ❑ Tank ID ❑ ❑ TanklD ❑ ❑ TanklD 01 ❑ Is the fill cap securely on the fill pipe? Tank ID 001 /Diesel /6 , 000gal ® ❑ Tank ID ❑ I . El TanklD ❑ ❑ Tank ID ❑ ❑ Is the under-dispenser containment free of damage , water , debris , and hazardous substance? Under- Dispenser Containment ID Y N NAI Under-Dispenser Containment ID Y N NA ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ ❑ X . TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? ® ❑ 08/ 13/ 19 Has the spill container testing been completed within the past 12 months ? X ❑ 08/ 13/ 19 Has the overfill prevention equipment inspection been completed within the past 36 months? ® ❑ ❑ 09/ 13/ 18 Has the secondary containment testing been completed within the past 36 months ? ® ❑ ❑ 08/24/ 17 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 : Cathodic Protection ® ❑ 08/23 / 17 Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ XI . FACILITY EMPLOYEE TRAININGY N Have all individuals performing facility employee duties received the required facility employee training within the past 12 months ? ® ❑ I 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