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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: wine Country Food&Gas Inspection Date: 1-1 o Facility Address: 1111 W. Kettleman Lane City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: — a International Code Council Certification No.: c Expiration Date: S -2 -t Signature: Phone: (916) 371-2380 ext. N/A=Not Applicable Item MONITORING PANEL/ALARM HISTORY Yesl No I N/A 1. Is the monitoring system powered on and in proper operating mode? 2. Is the monitoring system not currently showing any leak alarms? 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the Designated UST Operator? (Attach a c2a o the alarm history report/log to this ins ection ornt.) 4. Has each alarm rot the pievious month been res oit&d to a ro riatcly? - El— UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:lfthe answer to Item a was"Yes,"ship to Item 6.Sumps inhere an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and properly addressed,the cause o the alarm.t)acumenlation veri in a mate service should be attached to this report. Yet No "�" Ye! No Sum Location: Sunt Location: t Sump Location: ❑ Su112 Location: 6. Ares ill buckets(containment structures)free of water,debris,and hazardous substance? Yes No N/A I Yes No N/A Tank I ID-87 Tank 4 ID- Tank 2 ID-91El Tank 5 ID- Tank 3 ID-DSL Tank 6 ID- 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes No N/A Yes No I NIA Dispenser- 1/2 = Dispenser- Lj El I E Dis is enser- Dis enser-3/4 ® = Dispenser- LJ lt!f Dis is enser- Dis enser-5/6 Dispenser- Dis enser-7/8 Dispenser- 8. is enser- 8. Leak detection is ro erl located within under-dis enser containment. Yes No N/A Yes No N/A Dis enser- I/2 Dispenser Li Dis is enser- Dis enser-3/4 Dispenser- Dis enser-5/6 ❑ Dispenser- 17-7/8 ❑ Dispenser- PAPERWORK INSPECTION Yes No N/A Date Done 0.- 9. Monitorin S stem Certification was completed within the past 12 months? ❑ D 10. Line Leak Detectors were tested/certified within the past 12 months? v ❑ ❑ io e�ct 11, S ill bucket(containment structure)testin cont Ieted within the as[ I2 months. l2. Line ti htness testin cont leted within the re aired time frame? 0 12-11-2006 13. Seconda containment tests cont leted within the re uired time frame. 14. Enhanced Leak Detection completed within the re uired time frame? 15. Other re uired testirrujimainteriance was cont leted within required time frame? (List test/maintenance items below.) Describe TesdMaintenance: Air Quality ST 27&30 ❑ 6-15-2009 Describe Test/Maintenance: -. FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facilit em to ees received the re uired on-the-job trainin within the ast ear? 17. Have all facilit em to ees hired within the ast 30 da s received the required on-the-job trainin .?Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. Y/26/OS UN-037-12 www.onidocs.org