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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 III from the previous inspection been completed appropriately? Y N Attach documentation verifying appropriate service to this report. N ❑ VIII . ALARM HISTORY Attach a cony of the alarm history report1log report/logto this report. Y N INA Is the monitorings stem powered on and in proper operating mode? N ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ® ❑ ❑ Attach documentation verifying a oropriate 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 1X 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 001 /Diesel /6 , 000 Gallons ® ❑ Tank ID ❑ ❑ Tank ID ❑ ❑ Tank ID ❑ ❑ Is the fill pipe free of obstructions ? Tank ID 001 /Diesel/6 , 000 Gallons ® ❑ Tank ID ❑ ❑ Tank ID I LlI ElI Tank ID ❑ El Is the fill cap securely on the fill pipe? Tank ID 001 /Diesel/6 , 000 Gallons 19 1 ❑ I Tank ID I ❑ ❑ Tank ID ❑ El Tank ID El FO Is the under-dispenser containment free of damage , water , debris , and hazardous substance? Under-Dispenser Containment ID Y N I NAI Under-Dispenser Containment ID Y N NA ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ r❑ El ❑ El ❑ [I El El El El ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? 01 ❑ N X . TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months ? ® ❑ 08/02/ 18 Has the spill container testing been completed within the past 12 months ? ® ❑ 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 ? ® ❑ ❑ 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 Protection ® ❑ 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 ? N ❑ 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