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0 9 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> FacilityName: Lodi Food & Liquor Inspection Date: '( r .Z <br /> Facility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: 2 Expiration Date: <br /> Signature: Phone: (916) 371-2380 ext. <br /> N/A=Not A licable <br /> Item MONITORING PANEL/ALARM HISTORY Y s No I NIA <br /> I. Is the monitoring system powered on and in proper operating mode? 11611 ❑ 1 ❑ <br /> 2. Is the monitoring system not currently showing any leak alarms? 19 ❑ ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ ❑ <br /> Designated UST Operator? (Attach a co of the alarm history report/logreporillog to this ins ection orm) <br /> 4. 1 Has each alarm for the revious month been res onded to appropriately? <br /> a; ..e.;;,..,: �:� .... <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:lithe ans,ver to Item 4 was "Yes,"skip <br /> to Iters:6. Sumps where an alarm has occurred in the past month must be inspected if a gual fled service technician has not responded to, and <br /> properly addressed,the cause of the alarm.Documentation ver i in appropriate service should be attached to this re ay. <br /> Ye; No r Ye! No <br /> Sump Location: 13 Sump Location: <br /> Sum Location: - Sum Location: <br /> 6. Ares ill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID—87 Tank 4 ID— <br /> Tank 2 ID—91 Tank 5 ID— <br /> Tank 3 ID—DSL Tank 6 ID— <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes I No I N/A Yes No N/A <br /> Dispenser— 1/2 10 1 Dispense — <br /> Dis enser—3/4 Dispense — ❑ ❑ <br /> Dispenser—5/6 ❑ Dispenser— ❑ ❑ <br /> Dispenser—7/8 Dispenser— ❑ <br /> 8. Leak detection is proper-ly proper—1located within under-dispenser containment. <br /> Yes No N/A Yes NoI NIA <br /> Dispenser— 1/2 H I Lj I Dispenser— 0 <br /> Dis <br /> is enser— <br /> Dis enser—3/4 LLJJ I Dis enser— <br /> Dis enser—5/6 Dispenser— <br /> Dispenser—7/8 Dispense — <br /> . <br /> «..zr.o- AID <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was com leted within the past 12 months? 10 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? 1 Lj 11-29-2011 <br /> 11. Spill bucket containment structure testing completed within the past 12 months? El I Lj 11-29-2011 <br /> 12. Line tightness testing completed within the required time frame? <br /> 13. Secondary containment tests completed within the required time frame? 2-11-2011 <br /> 14. Enhanced Leak Detection completed within the required time frame? S3110 1 <br /> 15. Other required testin maintenance was completed within required time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance: Air Quality St 27&30 12-22-2011 <br /> Describe Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING UsNo N/A <br /> 16. Have all facility employees received the required on-the-job training within the past ear? ❑ <br /> 17. 1 Have all facili em to ees hired within the past 30 days received the required on-the-•ob training.? <br /> Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidoes.org 9/26/05 <br />