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UNDERGROUND STO GE TANK SYSTEM DESIGNATED UST OPERATORMNTHLY INSPECTION REPORT Facility Name: Lodi Food & Liquor Inspection Date: .7//7 la Facility Address: 1225 Lockford Street City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: Z International Code Council Certification No.: �'(�a�Y :_u Expiration Date: �� fid, /� Signature: Phone: (916) 371-2380 ext. N/A=Not A licable Item MONITORING PANEL/AL RM HISTORY Yes No N/A 1. Is the monitoring system powered on and in proper operating 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 copy of the alarm histoitv report/logreportllog to this ins ection orm.) 4. Has each alarm for the previous month been res onded to a o riatel ? " UST SYSTEM INSP CTION 5. Are tank-top containment sumps free of water,debris,and haz rdous substance? Note:If the answer to item 4 was "Yes,"skip to Item 6. Sumps where an alarm has occurred in the past month nr:rst be spected if a qualified service technician has not responded to,and ro err addressed,the cause o lire alarm.Documentation ver in a ro rate service should be attached to this report. Ye' I No Ye., No Sump Location: Suinp Location: ❑ Sum Location: Su Location: ❑ 6. Ares ill buckets(containment structures)free of water,debrisj and hazardous substance? Yes No N/A I Yes No N/A Tank 11D-87 Ta k4ID– El 11 tE Tank 2ID-91 — Ta k51D– #LJ ❑Tank 3 ID–DSLFTa k 6 ID– ❑ 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yesl No I N/A Yes No N/A Dispenser– 1/2 Ull El I Dis enser– ❑ - Dispenser–3/4 Dis enser– U 1 ❑ 1 ❑ Dispenser–5/6 LJ Dis enser– ❑ -El- Dispenser Dis enser–7/8LJ:iE IDis enser– ❑ 8. Leak detection is properly located within under-dis enser containment. Yes I No N/A I es I No N/A Dispenser– 1/2 Dist enser– I ❑ ❑ Dispenser–3/4 El Dist enser– I ❑ ❑ ' Dispenser–5/6 Erl. Dist enser– El I ❑ ❑ Dispenser–7/8 ElDis enser– ❑ ❑ ❑ PAPERWORK INSPECTION Yes No N/A Date Done 9. MonitoringSystem Certification was completed within the past 2 months? 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 moths? 11-29-2011 11. Spill bucket containment structure)testingcompleted within th past 12 months? 11-29-2011 12. Line tightness testingcompleted within the required time frame? 13. Seconds containment tests completed within the required time ame? 2-11-2011 14. Enhanced Leak Detection completed within the required time fra e? 15. Other required testing/maintenance was completed within re uir d time frame? (List test/ aintenance items below.) Describe Test/Maintenance:Air Quality St 27&30 9 El 10 12-22-2011 Describe Test/Maintenance: L_J F1 10 h . FACILITY EMPLOYEE TRAIN NG Ye No N/A 16. Have all facility employees received the required on-the-job train ng within the past ear? 17. Have all facili em to ees hired within the 2ast 30 da s receive the required on-the-ob training.? ❑ Note: Explain any"No"answers in the"Comments"section on the follo ing page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.uttidocs•org 9/26/05