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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Lodi Food & Liquor Inspection Date: 0, -( 5-/ 2— Facility Address: 1225 Lockford Street City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: International Code Cou 11 ification No.: Expiration Dater 2- .9-2 Signature: Phone: (916) 371-2380 ext. N/A=Not Applicable Item MONITORING PANEL/ALARM HISTORY Yes No N/A I. Is the monitoring system powered on and in proper operating mode? ❑ 2. Is the monitoring system not currently showing any leak alarms? ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ Designated UST Operator? (Attach a copy o the alarm hisimy report/logreport1log to this ins ection orm) 4. Has each alarm for the revious month been res onded to a ro riatel ? ❑ UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:if the ansiver to Item 4 was "Yes,"skip to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and properly addressed,the cause of the alarm.Documentation ver& in a ro riate service should be attached to this re ort. Ye. No Ye! No Sum Location: Sum Location: Sum Location: Sump Location: ❑ 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? Yes No N/AI Yes No N/A Tank l ID-87 Tank 4 ID- ❑ Tank.2 ID-91 Tank 5 ID- Tank 3 ID-DSL Tank 61D- 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Yes I No I N/A I Yes No N/A Dispenser- 1/2 Dispenser- Dispenser-3/4 El Dis enser- Dispenser-5/6 11 Ej I Dispenser- Dispenser-7/8 1 11 10 1 Dispenser El El W - 8. Leak detection is properly located within under-dispenser containment. Yes No N/A I Yes I No N/A Dispenser- 1/2 Dispenser- Dispenser-3/4 Dis enser- ❑ Dis enser-516 Dis enser- ❑ Dispenser-7/8 Dis enser IT - �> 777 PAPERWORK INSPECTION Yes No N/A I Date Done 9. Monitoring System Certification was completed within the past 12 months? n 1 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 months? F1 11-29-2011 11. Spill bucket containment structure)testing completed within the past 12 months? 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 14. Enhanced Leak Detection completed within the required time frame? In 15. i uired testin maintenance was com leted within re uired time frame? (List test/maintenance items below.) ribe Test/Maintenance:Air uali St 27&30 12-22-2011 ribe Test/Maintenance:FACILITY EMPLOYEE TRAINING Yes No N/A ll facili em to ees received the re uired on-the-'ob trainin within the ast ear? 17. ll facility em to ees hired within the 2ast 30 d!Xs received the required on-the-'ob trainin .? AS I El I EJ Note: Explain any"No"answers in the"Comments"section on the following page.Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.unidocs.org 9/26/05