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al to <br /> O U <br /> N Q1 <br /> -0 N <br /> v — <br /> t <br /> E � 0 ami <br /> Designated Underground Storage Tank(UST)Operator <br /> a +' o <br /> Monthly Visual Inspection Checklist a 0 <br /> O N <br /> Dareo <br /> : T �^ a� c i 0 <br /> —� O <br /> F'acilin Name: CITY OF LODI 4� <br /> N IZZI- <br /> Facility'Address: 1331 S.HAM LANE Zi Code:95240 d <br /> Ciu; L011I.CA _ O O <br /> Ex iro[ion Date: 06/0612016 U c-1 <br /> Desienated LIST 0 orator Conducting the Ins 14628:.1ESSE BERUMEN 209,367 4800 4! t1) to <br /> International Code Council Certification : 81114628LIC phone:( t3 <br /> =\nLA tieaftle O U <br /> Si,nffinrc: y' : N M1A c <br /> MONITORING PANEL/ALARM HISTORY Q +' o <br /> U Item _ X <br /> ` X ct — <br /> 1 Monitonn system is owercd on and in ro r o emtin_mode. X <br /> 9 Monivine system is not currently showing any alarms or++'oasis*s. L 4- Z <br /> U — <br /> O ; Alarm history'repos/log for the previous month is available,and has been reviewed byte (D O <br /> Desienated UST 0 emtor. l�nnc h a co r of the olar•nl htvhun,re urtJlo to this form i(a''ailuble.) +� 3 <br /> J 4 Each alaml for the previous month has been res responded to a ro riately. <br /> O t11 3 <br /> 5 Sensors located in tank-to containment sum s have not alarmed in the ant month. Q <br /> } O <br /> is List all lank-top sumps where alarms occltl in the past month: U <br /> N -0 +� <br /> J +� N ra <br /> Iceo +' -0 <br /> Nose Sumps mtmm all alarm has occur 1 i !7,t r r m,nd nmst be inspected unless <br /> a qua ice his report a- <br /> responded to•m! M N <br /> rh addressed lire cause�llh alar".I n:n do a nrnmriaa verifi,ing appropriateC — <br /> P .' axe: t <br /> lfsu In alimrisn urrrd,rcwnlr sale in rt r i l h Int. ,:.., � .0 •� F— <br /> UST SYSTEM INSPECTION v <br /> L <br /> 6 Tank-top containment sumps are fret of water debris.and hazardous substance. Sensors are located properly. 1 a) O <br /> Q <br /> Note:Puual rnsrt�ton olswn�s c,orh•re tared m corn rs where au alarm has occurred m llh st month/or++hich here r5 no,ervi Nrecard U v <br /> Y N 4J <br /> �--� Slmt.Locnim::. 11'FuelIslarid X SumLocalion: �, i O <br /> m <br /> Sum)Location: ,1 0 Fuel!stand X Sunr Location: LO OQ v <br /> m Sun! Location:N E Fuel lsland X Sum Location: v r1 <br /> 7 S ill containment structures are free of water,debris,and hazardous substance. v O <br /> Y N NA Y N NA to O -O <br /> L Tank I-Contemn:10.000 Unleaded X I Tank 3-Contents:5,000 Diesel X <br /> Q� T ank'_-Contents: '.000 I nleaded X Tank 4-Contents: t^ C C <br /> C <br /> 4-J S Under-dispenser containment areas are free of water.debris,and hazardous substance. Sensors are located ro eri +OLn .� <br /> Y N I NA Y N INA I U <br /> - (U <br /> Q� Din caner J'aluhi-ru;lurr I X i s <br /> U Dis encs' j O +' <br /> U <br /> Oisnerser 3 O O <br /> Oitlhnver 4 t E m <br /> V ..� . " O <br /> " <br /> •j PAPERWORK INSPECTION Y N I NA i DATE DONE O O '1N <br /> 9 ;hionitorin,system cenitication has been com feted within ant 12 months. X 09125/2014 � " = <br /> 10 .Secondan containment teats have been com feted veithin there aired timeframe. X ( 10/9/2014 -0 Q c <br /> 11 'Sill containment st acture ibucke[}tontine was com feted within the ant ear. X 9/25/2014 C: O O <br /> 1'_ 1'anl tiehatess tzstine vvas cam Ieted within re tired timeframe. X <br /> 1; l Linz tiehmvss testinexas completed within rt aired timeframe. X U , <br /> • i t thher rc tired tesnn maimenan,e ea:com feted within re tto <br /> ired timeframe. (Listies- I tenance items below— -r- <br /> C <br /> C <br /> TcS!I famr r r r e: .L1 NL'9L LEAK DETECTOR TEST — W <br /> Test 4h2"'cnanre:sBW SEi'Oe n ';,. X 9/25/2014 �O a) E <br /> aRl'C0�'Tan1. i TEST !092017 X 1(1ron014 -O -p C <br /> rert'tl ri„�_n,+n: Drop Ttrhe ln!egrin Tat even,i rs Due a r''1115' — <br /> j Tert,tiainteaiance:StakeToraue FRotation Test ren 3 r•rs Du•1! 1018 X ;•17/2015 v t rI rty <br /> I i t!_015to O 0 <br /> O FACILITI EMPIL)YEE TRAINING O <br /> C :V!t"aci'tin _ 1' I N NA� <br /> lovices have received the required on-the-job trainine within the ant year. X <br /> Aii;acilin m love h s u ithin rte pa t;0 du,s have received the re uired on-the-job trainine. tU a <br /> Note: Am ansm-up 3c Of ion. should be evptained in the comment section on the rollowing page,and will require O 4� <br /> !? O <br /> ioilow-up action. � v � <br /> 4; to to <br /> M v v N <br /> Page t of'_ � 44- 4-- <br /> Novem O <br /> "O 7N <br /> Q) O <br /> t M N to <br /> 4-+ -0 M d <br />