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Underground Storage Tank <br />Designated DST Operator Visual Inspection Report <br />S. OWNERIOPERATOR DESCRIPTION OF FOLLOW-UP ACTION <br />Number Ilia f0ow up actions to correspond Io appropriate compliance issues <br />Section 3 <br />6. OWN ER 1 OPERATOR AGKN0 W L,EDGEMENT OF INSPricTioN RESULTS <br />1 have reviewed the resuIts of the designated UST operator inspec#ion report and provided a <br />description of the actions) taken or to be taken to correct any oompiiamca Issues discGvered. <br />Marne of UST Owner 1 Operator (print) <br />UST Owner/Operator Signature <br />T. INSPECTION 141STORY <br />Date Signed <br />Has each follow-up acton of Section 3 From the previous Designated UST <br />Operator Inspection Deport been completed appropriately" <br />(l aclr docufnigntalion erf gppropnele S6rvjce to this repof t, ) <br />B. IRELF-ASE DETECTION ALARM HISTORY <br />Attach a cop} of the alarm history regorVlog to this report. <br />is the monitoring System powered on anal in proper operating mode? <br />Has each warm since the previous inspection been responded to appropriately? <br />(Aftach docLime #tabor verifying appropriate service to tljis reporj.) <br />Have a)J containment sumps, that have had are alarm since the previous <br />designated UST operator inspection report, been responded to by a qualified <br />service technician? <br />Yes 1 o f NA <br />❑ II Cl El <br />Yes No NA <br />All answers +parked "No"must be des rrbed by the designated UST Operator in Sechon 3_ <br />Wage 2 of 4 <br />