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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. ® ❑ VIII . ALARM HISTORY Attach a cony of the alarm history report/logreportliog to this report, Y N NA Is the monitoring system powered on and in proper operating mode? X ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ® ❑ ❑ Attach documentation verifving 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 X ❑ ❑ ualified 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 001 /Diesel /6 , 000 Gallons X ❑ Tank ID 01 ❑ Tank ID I ❑ ❑ Tank ID ❑ ❑ Is the fill pipe free of obstructions ? Tank ID 001 /Diesel/6 , 000 Gallons ® ❑ Tank ID ❑ ❑ Tank ID I ElI ElI Tank ID El Is the fill cap securely on the fill pipe? Tank ID 001 /Diesel/6 , 000 Gallons 10 1 ❑ Tank ID ❑ ❑ Tank ID El El Tank ID El ❑ Is the under-dispenser containment free of damage , water , debris , and hazardous substance? Under-Dispenser Containment ID Y I N I NAI Under-Dispenser Containment ID Y N NA ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ EEI El El El El ElEl El El El El❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ ❑ X 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? X ❑ ❑ 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 ? ❑ ❑ X Has the line tightness testing been completed within the required timeframes ? ❑ ❑ X Other required testing / maintenance was completed within required timeframe . (List test/maintenance items below. ) Test / Maintenance : Cathodic Protection X El 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 ❑ ! 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