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l � � UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Flag City Chevron Inspection D . ,U17 V Facility Address: 6421 Capital Ave City: Lodi DEC ,,, Name of Designated UST Operator Conducting Inspection: Alex Jabbari International Code Council Certification No.: 5243897-UC WiLe N18TH Signature: Phone:D T380'21162 N/A=Not Applicable Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. Is the monitoringsystem powered on and in proper operating mode? 2. Is the monitoringsystem not currentlyshowingan 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 co o the alarm histo re ort/lo . to this ins ection orm 4. Has each alarm for the previous month been responded to appropriately? ❑ El UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water, debris, and hazardous substance? Note:If the answer to Item a was "Yes,"or "NA"skip to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a quaked service technician has not responded to,andproperly addressed the cause o the alarm.Documentation verifying appropriate service should be attached to this report. No sumps alarm Yes I No Yes No Sump Location: El Sump Location: ❑ Sump Location: Sump Location: 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/A I Yes No N/A Tank 1 ID—Regular Master 2 1 El I El I Tank 3 ID—Premium Tank 2 ID—Regular Salve Z I Lj I E I Tank 4 ID—Diesel Z El 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes I No I N/AI Yes No N/A Dispenser— 1/2 E I El I Dispenser—9/10 ❑ Dispenser—3/4 E Dispenser—11/12 Dispenser—5/6 E El El I Dispenser—13/14 EF Dispenser—7/8 = ❑ I Dispenser—15/16 8. Leak detection is properly located within under-dispenser containment. Yes I No I N/A I No N/A Dispenser—1/2 1 Ll ❑ Dispenser—9/10 1 [Ell Dispenser—3/4 Dispenser—11/12 Dispenser—5/6 ® ❑ Dispenser—13/14 El El Dispenser—7/8 ® ❑ ❑ Dispenser— 15/16 PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? ® ❑ ❑ 9/26/2016 10. Secondary containment tests completed within the required time frame? ❑ 1/20/2016 11. Spill bucket(containment structure)testing completed within the past 12 months? 9/26/2016 12. Tank tightness testing completed within the required time frame? E Ll13. Line tightness testing completed within the required time frame? 4 =1 Z 15. Other re wired testing/maintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance:Air Quality I X I L I El 1 9/26/2016 Describe Test/Maintenance: I ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job training within the past ear? 17. Have all facility employees 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.