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0 0 <br /> UNDERGROUND STOILWE TANK SYSTEM <br /> hESIGNATED UST OPERATOR MC NTHLY INSPECTION REPORT <br /> Facility Name: Lodi Food & Liquor Inspection Date: <br /> Facility Address: — <br /> 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: C4lZ <br /> Expiration Date: <br /> Signature: <br /> Phone: (916)371-2380 ext. <br /> Item MONITORING L/AL RM HISTORY N/A=Not A licable <br /> I. Is the monitorin s stem owered on and in ro er o eratin ode? Yes No N/A <br /> 2. Is the monitoring system notcurrently showin an leak alarm 7 1:1 <br /> 3. Is the Alarm History Report/log for the previous month availab e,and has it been reviewed by the El ❑ <br /> Desi nated UST O erator? (Attach a co o the alarm histo re or0o to this Inspectionorm. <br /> 4 Has each alarm for the previous month been res onded to a r riatel ? <br /> UST SYSTEM INSP CTION � <br /> 5. Are tank-top containment sumps free of water,debris,and haza dous substances Note:trthe answer to!tern 4 was Yes, skip <br /> to/tent 6.Sumps where an alarm has occurred in the past month mast be ' pecied if a qualified service techniclan has not responded to, and <br /> Meerlx addressed,the cause qf the alarm.Documentation vert In a ro r to service should be attached to this re ort. <br /> Ye! No Yet No <br /> Sum Location: Su Location: <br /> Sum Location: Sum Location: ❑ ❑ <br /> 4 Are s ill buckets(containment structures)free of water,debris, nd hazardous substance? <br /> Yes No N/A <br /> Tank 1 ID—87 Tan Yes No N/A <br /> 4 ID— <br /> Tank 2 ID—91 Tant 5 1D— __ El ❑ <br /> Tank 3 ID-DSL Tan 6 ID— — <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Ye No N/A Yes N0 N/A <br /> Dispenser— 1/2 Dis nser— <br /> Dis enser—3/4 Dis nser— ElDispenser—5/6 Dis nser— ❑ ❑ <br /> Dispenser—7/8 Dis nser— ❑ <br /> 8. Leak detection is properly located within under-dispenser contain ent. <br /> Yes No I N/A Yes No N/A <br /> Dispenser— 1/2 1 Li I _R!!pa ser— ❑ <br /> Dispenser—3/4 Li I Dispe iser— ❑ <br /> Dispenser—5/6 Dis a iser— ❑ El I ❑ <br /> Dispenser—7/8 Dis a ser— <br /> 777 <br /> PAPERWORK INSPECTION Yes)-No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 11 months? I Ll <br /> 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 mont s? Z El I El 11-29-2011 <br /> 11. Spill bucket containment structure)testing completed within the ast 12 months? 11-29-2011 <br /> 12. Line tightness testing com leted within the required time frame? <br /> 13. Secondary containment tests completed within the required time f me? 2-11-2011 <br /> 14. Enhanced Leak Detection completed within the required time fra e? <br /> 15. Other required testing/maintenance was completed within requirec requiretime frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance:Air ual! St 27&30 12-22-2011 <br /> Describe Test/Maintenance: Ti F1 <br /> FACILITY EMPLOYEE TRAINI NIG Yes mJ No N/A <br /> 16. Have all facility employees received the required on-the-job trainhig within the past ear? :4�R= <br /> 17. Have all facili em Io ees hired within the.Last 30 da s received 4he required on-the-'ob trainin .? <br /> Note: Explain any"No"answers in the"Comments"section on the folio ing page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidoes.org 9/26/05 <br />