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UNDERGROUND ST®RA E TANK SYSTEM DESIGNATED UST OPERATOR MO THLY INSPECTION REPORT Facility Name: Lodi Food & Liquor I spection Date: 4 Z t!�Z Facility Address: 1225 Lockford Street ity: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: International Code Council Certification No.: 2 Ci txpiration Date: /Oi' /, Signature: Phone: (916) 371-2380 ext. N/A=Not Applicable Itein MONITORING PA EL LA M HISTORY Yes o N/A 1. Is the monitoring system powered on and in to er o in in de? E] ❑ 2. Is the monitoringm not c s steurrent! showin any leak alarms ❑ 11 3. is the Alarm History Report/log for the previous month availabl ,and has it been reviewed by the El Designated UST Operator?.. Attach a co v o the alarm histo eportllog to this Inspection orm. ❑ 4. Has each alarm for the revious month been res onded to a ro irate! ? MUM III[ UST SYSTEM INSPE TION F5. Are tank-top containment sumps fi•ee of water,debris,and haza dour substance? Note:/f the ansiver to Item 4 was "Yes,"skip to!tent 6.Sumps inhere an alarm has occurred in the past month must be in ecied if a qualified service technician has not responded to, and ro erl addressed,the cause o the alarm.Documentation ver' in a ro ri to service should be attached to this re ort. Ye! No Ye! No Sump Location:' Sum Location: ❑ Sump Location: Su Location: 6. Ares ill buckets(containment structures fi ee of water,debris,4nd hazardous substance? yes No N/A Yes No N/A Tank 1 .iD—87 Tan 4 ID— Tank 2 ID—9 I Ta 5 ID— Tank 3 ID—_DSL - - - ^Tan 6113= ❑ 7. Are under-denser containment areas free of water,debris,an hazardous substance. yes No N/A Yes No N/A Dispenser— 1/2 $0 Dis enser— -- Dispenser—3/4 Dis enser— ❑--i� Dispenser—5/6 Disl enser— ❑-1 Dis enser -7/8 01 Dis enser— ❑ �. Leak detection is properly located within under-dispenser conta nment. yes No N/A Yes No N/A ❑ El enser— 1/2 Dis enser— Dis enser—3/4 Dis enser— El Dis enser—5/6 Dis enser— Q LJ Dispenser—7/8 Dis enser— ❑ Yes No N/A Date Done PAPERWORK INSPECTION -- 9. Monitoring S stem Certification was com feted within thepast 2 months? 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 mo ths? 11-29-2011 11. Spill bucketcontainment structure testin completed within thpast 12 months? 11-29-2011 T2_7 Line tightness testing com leted within the re uired time frame 2-11-2011 13. Secondary containment tests completed within the required tinic frame? 14. Enhanced Leak Detection cornleted within the re uired time ft me? 15. Other re uired testing/maintenance was completed within re ui ed time frame? List test/ aintenance items bel Describe Test/Maintenance:Air ualt St 27&30 Rr 12-22-220101 1 _ Describe Test/Maintenance: ....,±, , FACILITY EMPLOYEE TRAI ING Yes No N/A 16. Have all facility employees received the required on-the-iob tra•nin within the vastear? _ 17. Have all facility employees hired within the past 30 days receiv d the required on-the-'ob trainin .? Note: Explain any"No" answers in the"Comments"section on the fol owing page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.unidocs.org 9/26/05