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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> FacilityName: Wine Country Food&Gas Inspection Date: _ 3L <br /> ) .7 <br /> Facility Address: 1111 W. Kettleman Lane City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: �ZS �z Expiration Date: <br /> Signature: Phone: (916)371-2380 ext. <br /> N/A-Not A licable <br /> Item MONITORING PANEL/ALARM HISTORY Yesl No I N/A <br /> 1. Is the monitoring system powered on and in proper operating model I Li I Li <br /> 2. Is the monitorinR system not current!y showing any leak alarms? <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Designated UST O erator`7 (Attach a copy of the alarm history report/7oreportl7og to this inspection arm. <br /> 4. Has each alarm for thUrevious month been responded to appropriately? <br /> UST SYSTEM INSPECTION <br /> S. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:if the answer to item 4 was'Yes."skip <br /> to Item 6. Sumps where an alarm has occurred in Me past month must be inspected if a qualified service technician has not responded to, and <br /> properly addressed,the cause o me alarm.Documentation AV= <br /> te service shau(d be attached to thi3 reort. Yet No <br /> Location: <br /> Sump Location: I Lj I Lj MM Sump Location: I Li I Li <br /> 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID-87 Tank 4 ID- <br /> Tank 2 ID-91 1 1 Ll I Lj I Tank 5 ID El W <br /> - <br /> Tank 3 ID-DSL Tank 6 ID- <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes I No I N/A I Yes No N/A <br /> Dispenser-1/2 01 0 1 Lj I Dispenser- -0 ER I <br /> Dis <br /> is enser- <br /> Dis enser-3/4Dis enser- <br /> Dispenser-5/6VR4Dis enser- <br /> Dispenser-7/8 Dispenser- El I Q2, <br /> 8. <br /> is enser- <br /> 8. Leak detection is properly located within ander-dis enact containment. <br /> Yes No N/A Yes No I NIA <br /> Dispenser-1/2 1 Dispenser- <br /> Dispenser-3/41 Disenser- <br /> Dispenser-5/6 Dis enser- <br /> Dispenser-7/8 Disaenser- <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitorin S stem Certification was co2pleted within the past 12 months? <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? AA I <br /> uccompleted •Iu'� 7r-0 1 <br /> 11. Spill bucket containment strture)testing com leted within the past 12 months? 1b01�r;0'� <br /> 12. Line tightness testing completed within the required time frame? <br /> 13. Secon containment tests com leted within the re uired time frame? 12-11-2008 <br /> 14. Enhanced Leak Detection completed within the required time frame? Ej <br /> 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. <br /> Describe Test/Maintenance: Air Quality ST 27&30 Q I El 1 6-15-2009 <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facilityemployees received the required on-the-job tramin within the past ear? <br /> 17. Have all facility employees hired within the past 30 days received the require d on-the-job training.? <br /> Note: Explain any"No"answers m the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidocs.org 9126/05 <br />