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I • • <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Wine Country Food &Gas Inspection Date: I_;,(—10 <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.: 5252 z7 Expiration Date: <br /> Signature: Phone: (916)371-2380 ext. <br /> N =NotApplicable <br /> Item MONITORING PANEL/ALARM HISTORY Yes No I N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? El <br /> 2. Is the monitoring system not currently showing any leak alarms? 7R Li <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the <br /> Designated UST Operator? (Attach a co .of the alarm histo2 rTortllog to this ins ection orm) <br /> 4. Has each alarm for the previous month been responded to appiopt iatcl ? <br /> ;3;1� Zill L <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:tribe answer to Item 4 was"Yes,"skip <br /> to Item 6. Sumps where an alarm has occurred in the past month most be inspected if a qualified semi"technician has not responded to,and <br /> properti addressedthe cause o the alarm.Docu n sivation veri in Fast service should be attached to this re ort. Yet No <br /> Sum Location:Sum Location: m Location: I L 1 ❑ <br /> 6. Ares ill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Yes No N/A I N/A <br /> Tank I ID-87 Tank 4ID— <br /> Tank 21D-91 1 ❑ I ❑ I Tank 5ID— <br /> Tank 3 ID—DSL I Lj I I I I Tank 6 ID— <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A Yes FRo N/A <br /> Dispenser—1/2 Dispenser— <br /> Dispenser—3/4 Dispenser— L I L I UL <br /> Dis <br /> is enser— <br /> Dis enser-5/6 Dispenser— OTMLEAF <br /> Dis <br /> is enser— <br /> Dis enser-7/8 Dispenser— <br /> 8. <br /> is enser- <br /> 8. Leak detection is properly located within under- is enser containment. <br /> Yes No N/A Yes No N/A <br /> Dispenser— 112 ❑ Dispenser— Li 0 <br /> Dis <br /> is enser— <br /> Dis enser-3/4 Dispenser— <br /> Dispenser—516 <br /> is enser— <br /> Dispenser-516 Dispenser— <br /> ! Dispenser-7/8 ❑ ❑ Dispenser— <br /> PAPERWORK INSPECTION <br /> is enser— <br /> PAPERWORKINSPECTION Yes No N/A Date Donne <br /> 9. MonitoringSystem Certification was completed within the past 12 months? ❑ <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? (����'—� <br /> 11. Spill bucket(containment structure)testing completed within the past 12 months! al <br /> 12. Line tightness testing completed within the required time frame? Li <br /> l3. Secondarycontainment tests completed within therequired time frame? 12-11-2008 <br /> 14. Enhanced Leak Detection completed within the required time frame? <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 6-15-2009 <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facili employees received the required on-the-'ob training within the past ear? <br /> 17. Have all facility employees hired within the ast 30 da s received the re uired on-the=ob trainin <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-L2 www.unidocs.org 9/26105 <br />