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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 re ort. Y N INA Is the monitoring system powered on and in proper operating mode? N ❑ ❑ Has each leak detection alarm since the previous inspection been responded to appropriately? ® ❑ ❑ Attach documentation verifving a prooriate service to this report. Have all containment sumps that have had a leak detection alarm since the previous inspection been responded to by a ® El F1ualified 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 FIST 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 N ❑ Tank ID ❑ FO Tank ID El El Tank ID ❑ Is the fill pipe free of obstructions ? Tank ID 001 / Diesel/6 , 000gal ® ❑ Tank ID ❑ ❑ Tank ID 101 ❑ I Tank ID I ❑ ❑ Is the fill cap securely on the fill pipe? Tank ID 001 /Diesel/6 , 000gal ® ❑ Tank ID ❑ ❑ Tank ID El ❑ Tank ID ❑ ❑ 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 I N NA 01 ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ 1:11 ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 ❑ Are all sensors in under-dispenser containment located to detect a leak at the earliest opportunity? ❑ ❑ Xl X . TESTING AND MAINTENANCE Y N NA Date Last Performed Has the monitoring system certification been completed within the past 12 months ? N ❑ 08/ 13/ 19 Has the spill container testing been completed within the past 12 months ? N ❑ 08/ 13/ 19 Has the overfill prevention equipment inspection been completed within the past 36 months ? N ❑ ❑ 09/ 13 / 18 Has the secondary containment testing been completed within the past 36 months ? N ❑ ❑ 08/24/ 17 Has the tank tightness testing been completed within required timeframes ? ❑ ❑ Has the line tightness testing been completed within the required timeframes ? ❑ ❑ N Other required testing / maintenance was completed within required timeframe . (List tesbmaintenance items below. ) Test / Maintenance : Cathodic Protection N ❑ 08/23 / 17 Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ Test / Maintenance : ❑ ❑ XI . FACILITY EMPLOYEE TRAINING )ITN 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 = Uentification