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{ ' UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Flag City Chevron Inspection Date: 11/1/16 Facility Address: 6421 Capital Ave City: Lodi Name of Designated UST Operator Conducting Inspection: Alex Jabbari International Code Council Certification NO.: 5243897-UC o ate__ 10/3/2018 Signature: Phone: ' 925) rF- 389-1262 N/A=Not-Applicable Item MONITORING PANEL/ALARM HISTORY Yes No I N/A 1. Is the monitoring stem powered on and in proper operating mode? 2. Is the monitoring stem 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 USTOperator? Attach a copy of the alarm history report/logreport/log to this ins ection orm. 4. Has each alarm for the previous month been responded to appropriately? UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris, and hazardous substance? Note:If the answer to Item 4 was "Yes,"or NA"skip to Item 6.Sumps where 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 of the alarm.Documentation verifyinR appropriate service should be attached to this report. L9: 91 fill sump alarm Yes No Yes No x � 'r Sum Location: Sum Location: Sump Location: 77 11 P, Sump Location: 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/AYes No N/A Tank 1 ID-Regular Master ❑ El Tank 3 ID-Premium 1-1 IT- Tank 2 ID-Regular Salve Tank 4 ID-Diesel 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes No N/A Yes No N/A Dispenser-1/2 Dispenser-9/10 1 El Dispenser-3/4 Dispenser-11/12 Dispenser-5/6 ❑ L1 I Dispenser-13/14 tEl Dispenser-7/8 Dispenser-15/16 8. Leak detection is properly located within under-dispenser containment. Yea I No N/AI Yes No N/A Dispenser-1/2 19 1 EJ I Dispenser-9/10 Dispenser-3/4 X 0 Lj I Dispenser::-11/12 Dispenser-5/6 Dispenser-13/14 Q 4E Z Dispenser-7/8 Dispenser- 15/16 El PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the past 12 months? ® El M 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? 13. 1 Line tightness testing completed within the required time frame? 15. Other required testing/maintenance was completed within required time frame? (List test/maintenance items below. Describe Test/Maintenance:Air Quality I Z I El I Lj 9/26/2016 Describe Test/Maintenance: I L1 I L1 10 Y - FACILITY EMPLOYEE TRAINING Yes No VN/A 16. Have all facility employees received the required on-the-job train' within the past ear? 17. 1 Have all facili em to ees hired within the past 30 da s received the re iced on-the job trainin .? D El Note: Explain any"No"answers in the"Comments" section on the following page. Those issues require corrective action from the UST owner/operator.