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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. X ❑ VIII . ALARM HISTORY Attach a cony of the alarm history reportliog to this report. Y N NA Is the monitoring system powered on and in properoperating mode? N ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? X ❑ ❑ 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 ® ❑ ❑ 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 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 I N Containment Sump ID Y N ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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? eeeeeeeeee Tank ID 001 /Diesel/6 , 000 Gallons ® ❑ Tank ID ❑ ❑ Tank ID El Tank ID El FO Is the fill pipe free of obstructions ? Tank ID 001 /Diesel/6 ,000 Gallons X ❑ Tank ID ❑ ❑ Tank ID I ❑ I ❑ I Tank ID ❑ ❑ Is the fill cap securely on the fill pipe? Tank ID I 001 /Diesel /6 ,000 Gallons ® ❑ Tank ID ❑ ❑ Tank ID L I ❑ ❑ I Tank ID ❑ ❑ Is the under-dispenser containment free of damage , water, debris , and hazardous substance ? Under-Dispenser Containment ID Y I N INA Under-Dispenser Containment ID Y N NA FD El E] El ❑ L1❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ I ❑ LN X . TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months? X ❑ 08/02 / 18 Has the spill container testing been completed within the past 12 months ? X ❑ 08/02/ 18 Has the overfill prevention equipment inspection been completed within the past 36 months ? N ❑ ❑ 08/02/ 18 Has the secondary containment testing been completed within the past 36 months ? X ❑ ❑ 08/24/ 17 Has the tank tightness testing been completed within required timeframes ? ❑ ❑ N Has the line tightness testing been completed within the required timeframes ? ❑ ❑ N Other required testing / maintenance was completed within required timeframe . (List test/maintenance items below. ) Test / Maintenance : Cathodic Test ❑ ❑ 08/23/ 17 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? X ❑ I the facility has more components than this form accommodates, additional copies of this page may be attached. Y = Yes , N = No, NA = NotApplicable, ID = Identification