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0 9 <br /> UNDERGROUND STORAGFE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Lodi Food & Liquor [Iiispection Date: „_2—_ ,._ <br /> Facility Address; 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: Vj <br /> International Code Council Certification No.: ,� C Expiration Date:ERVS '17-12,7-1 -rSi—gnature: Phone: (916) 371-2380 ext. <br /> NA=Not A licable <br /> Item MONITORING PANEL/ALA kM HISTORY Yes No N/A <br /> 1. Is the monitoring system powered on and in ro er o eratin mode? ❑ <br /> 2. Is the monitoringsystem not currentlyshowingan leak alarms. ❑ L1 <br /> 3. Is the Alarm History Report/log for the previous month availabl ,and has it been reviewed by the ❑ F] <br /> Designated UST Operator? (Attach a co o the alarm histo eportllog to this inspectionform.) <br /> 4. Has each alarm for the revious month been responded to appro riatel ? ❑ 0 <br /> 1-1 ...r:•, UST _ <br /> SYSTEM INSPE TION <br /> 5. Are tank-top containment sumps free of water,debris,and haze dous substance? Note:lfthe ans,ver to Ire»t 4 was "Yes,"skip <br /> to Iters:6.Sumps inhere an alarm has occurred in the past month must be in petted if a qualified service technician has not responded to,and <br /> 77 <br /> ro erl addressed,the cause o the alarm.Do <br /> mentation ver' in a ro ri to service should be attached to this report. <br /> Ye' No Ye! No <br /> El <br /> Sum Location: Su Location: <br /> Sum Location: ` ` Su Location: <br /> 6. Ares ill buckets containment structures)free of water,debris, nd hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID—87 Tan 4 ID— <br /> Tank 2 ID—91M J: 5 ID— _., <br /> Tank 3 ID—DSL Tan 6 ID— ❑ <br /> 7. Are under-dispenser containment areas free of water,debris,an hazardous substance? yes No N/A <br /> es No N/A <br /> Dispenser— 1/2 Dispenser— <br /> Dispenser—3/4 Dis enser— <br /> Dispenser—5/6 Distenser— ❑ <br /> Dispenser—7/8 Dis enser— ❑ <br /> 8. Leak detection is properly located within under-dis enser conta nment. Yes No N/A <br /> Yes No N/A <br /> Dispenser— 1/2 bis enser— ❑ <br /> Dis enser—3/4 Dis enser— ❑ ❑ <br /> Dispenser—5/6 Vj <br /> Dis enser— ❑ <br /> Dis enser 7/8 <br /> Dis enser <br /> N <br /> PAPERWORK INSPECTION Yes No /A Date Done <br /> 9, MonitoringSystem Certification was completed within the past 12 months? 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 mo ths? 11-29-2011 <br /> 11. Spill bucket containment structure testingcompleted within th past 12 months? 11-29-2011 <br /> 12. Line ti fitness testingcompleted within the required time frame <br /> r5.14. <br /> Secondarycontainment tests completed within the required tim frame? 2-11-2011 <br /> Enhanced Leak Detection completed within the required time fr me? <br /> Other required testin maintenance was completed within requil ed time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance:Air Quality St 27&30 R 12-22-2011 <br /> Describe Test/Maintenance: <br /> 3 4_7 PRI I IREP I <br /> FACILITY EMPLOYEE TRAI 14ING Yes No N/A <br /> 16. Have all facility em to ees received the required on-the-job tra ning within the past ear? ❑ <br /> 1 1 <br /> 17. Have all facilityem to ees hired within the past 30 days receiv d the required on-the-'ob trainin -9 <br /> Note: Explain any"No"answers in the"Comments"section on the fol owing page.Those issues require corrective action from <br /> the UST owner/operator. <br /> www.unidocs.org 9/26/05 <br /> LIN-057-1/2 <br />