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UNDERGROUND STOGE TANK SYSTEM DESIGNATED UST OPERATOR M NTHLY INSPECTION REPORT Facility Name: Lodi Food & Liquor Inspection Date: x/30 AZ Facility Address: 1225 Lockford Street City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: vbt, (5V 7— International International Code Council Certification No.: (.r Z 2 _ C Expiration Date: Signature: Phone: (916) 371-2380 ext. N/A=Not A licable Item MONITORING P /AIJARM HISTORY Yes o N/A 1. Is the monitoring system powered on and in proper o eratin ode? ❑ 2. Is the monitoring system not currently showing any leak alar s. ❑ ❑ 3. Is the Alarm History Report/log for the previous month avails le,and has it been reviewed by the ❑ ❑ Designated UST Operator? Attach a co of the alarm histoltv report/logreport1log to this inspection orm. 4. Has each alarm for the previous month been res onded to a o riatel ? 111 -, UST SYSTEM INSP CTION 5. Are tank-top containment sumps free of water,debris,and ha rdous substance? Note:If the answer to Iter:d was "Yes, skip to Item 6. Sumps where an alartn has occurred in the past month nrast be nspected f a qualified service technician has not responded to, and properly addressed,the cause o the alarm.Documentation ver !n a ro tate service should be attached to this re ort. Yes I No Ye. No r h; Stimp Location: Suinp Location: Li Sum Location: Sujnp Location: ❑ t 6. Ares ill buckets(containment structures)free of water,debris and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID—87 Ta4k 4 ID— ❑ Tank 2ID-91 Ta k5ID— Q ❑ 'Tank 3 ID—DSL Ta k 6 ID— k7. Are under-dispenser containment areas free of water,debris,an hazardous substance? YesJ No I N/A I I Yes No N/A Dispenser— 1/2 Dis enser— Dispenser—3/4 Dis enser— ❑ ❑ Dispenser—5/6 Dis enser— Dis enser—7/8 Dis enser— RDateDone 8. Leak detection is ro erl located within under-dis enser conta nment. Ye No N/A Dis enser— 1/2 Dis enser— El Dis enser—3/4 Dis enser— Dis enser—5/6 Dis enser— ispenser—7/8 Dis enser—PAPERWORK INSPECTION Yes No N/A9. Monitorin S stem Certification was com leted within the ast 2 months?10. Line Leak Detectors were tested/certified within the ast 12 mo ths? 11-29-201 I I. Spill bucket containment structure testing completed within th4 past 12 months? M 11-29-2011 12. Line tightness testing completed within the required time frame? 13. Secondary containment tests completed within the required time frame? 2-11-2011 r7 1 14. Enhanced Leak Detection completed within the required time fr e? 75. Other required testinglinaintenance was completed within re uir d time frame? (List test/ alntenance items below) Describe Test/Maintenance:Air Quality St 27&30 2-17-2011 Describe Test/Maintenance: FACILITY EMPLOYEE TRAINING Yes No /A 16. Have all facility employees received the required on-the-'ob trair(ing within the paTt ear? 17. 1 Have all facili em to ees hired within the East 30 days received the required on-the-'ob training-? Note: Explain any"No" answers in the"Comments"section on the foil Ing page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 \Y{Yw.UnifiOes.t)rs 9/26/05