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• 0 -�' UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: wine Country Food &Gas Inspection Date: Facility Address: 1111 W. Kettlernan Lane City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: J, 3r e,J j International Code Council Certification No.: S�_57O f ' rJ t- Expiration Date: Signature: - Phone: (916)371-2380 ext. N/A=Not Applicable Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. Is the monitoring system powered on and in proper operating mode? 23 0 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 Desi nated UST Operator? (Attach a copy of the alarm histoty report1log to this ins ection orm.) . 4. Has each alarm for the revious month been responded to aooro riately? 6Z ❑ UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:lJthe annver to Item 4 was"Yes, skip to Item 6. Sumps where an alarm has occurred in the past month must be inspected iia qualified service technician has not responded to,and properlyaddressed due muse al the alarm.Documentation verlfline a ro riate service should be attached to this report. Yea No isI Yes I No Sump Location: I Li I Li I I Sump Location: Li Sump Location: I ❑ I ❑ Sum Location: 6. Ares ill buckets(containment structures)free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Tank I ID-87 ❑. Tank41DEl F-1 - Tank2ID-91 Tank51D- Tank 3 ID-DSL I I Ll I L I Tank 6 ID- 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes I No N/A Yes No N/A Dispenser- 1/2 Dispenser- -0 El I Ll Dis is enser- Dis enser-3/4 Dis enser- ❑ ❑ Dispenser-516 Dis enser- Q El LJ Dispenser-7/8 itg I ❑ I L I Dispenser- Leak is enser- Leak detection isro erl located within under-dis enser containment. Yes No N/A Yes No N/A Dispenser- 1/2 ❑ ❑ Dis enser- El El 11Dispenser-3/4 Dis enser- '. Dispenser-5/6 Dis enser- _ ❑ Dispenser-T8 -❑ , ❑ ❑ Dispenser- — PAPERWORK INSPECTION ' Yes ' No iN/Ai Harp nt,ne 9. Monitoring System Certification was completed within the past 12 months? ® 0=10- 30--Cl ' 10. Line Leak Detectors were tested/certified within the past 12 months? 1040--0 11. Spill bucket(containment structure)testing completed within the past 12 months? N LJ LJ I 12. Line tightness testin completed within the required time frame? ❑ ❑ ❑ 13. Secondary containment tests completed within therequired time frame? 012-11-2008 14. Enhanced Leak Detection completed within the required time frame? ❑ 15. Other required testing1mainteriance was completed within required time frame? (List test/maintenance items below.) Describe Test/Maintenance: Air Quality ST 27&30 6-15-2009 Describe Test/Maintenance: I ❑ I ❑ I ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. 1 Have all facility em to ees received the re uired on-the-job training within the past ear? ❑ I= 17. 1 Have all facility em to ees hired within the past 30 days received the required on-the-job training.? ❑ ❑ Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.anidocs.org 9/26/05