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0 9 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Lodi Food & Liquor Inspection Date: 3 1 <br /> Facility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: EJ, r � <br /> International Code Council Certification No.: 2�'� 2 Expiration Date: L.L _*7 ,Z <br /> Signature: Phone: (916) 371-2380 ext. <br /> N/A=Not Applicable <br /> JIDesip,nated <br /> MONITORING PANEL/ALARM HISTORY Yes No JE <br /> monitorin s stem powered on and in proper operating mode? ® ❑ <br /> monitoring system not current/ showingan leak alarms?Alarm History Report/log for the previous month available,and has it been reviewed by th <br /> UST O erator? Attach a co o the alarm histo re ort/lo to this ins ection orm.ch alarm for the previous month been responded to a ro riatel ? 101 Q I F <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item a was "Yes,"slop <br /> to Item 6.Sumps where an alarm has occurred in the past month must be inspected if a qual{Jled service technician has not responded to, and <br /> ro erl addressed,the cause o the alarm.Documentation ver& in a ro riate service should be attached to this re ort. <br /> Ye, No <br /> Ye; No <br /> Sump Location: <br /> Sump Location: El I <br /> ; <br /> Sum Location: <br /> Sum Location: <br /> 6. Ares ill buckets containment structures free of water,debris,and hazardous substance? <br /> Yes No N/AI I Yes No N/A <br /> Tank 1 ID—87 Tank 4 ID— H ❑ <br /> Tank 2 ID—91 Tank 5 ID— FFJI ❑ <br /> Tank 3 ID--DSL Tank 61D­ <br /> 7. <br /> 1D-7. Are under-dis enser containment areas free of water,debris,and hazardous substance? <br /> Yes I No N/A I Yes I No N/A <br /> Dispenser— 1/2 Dispenser— ❑ <br /> Dispenser—3/4 97= Dispenser— <br /> Dispenser—5/6Dispenser— <br /> Dispenser <br /> is enser—Dis enser—7/8 Dispenser— ❑ ❑_ <br /> g. Leak detection isro erl located within under-dis enser containment. <br /> Yes i No N/A I Yes I No I N/A <br /> Dispenser— 1/2 Dispenser— ❑ <br /> Dispenser—3/4 Dispenser— ❑ ❑ <br /> Dispenser—5/6 Dispenser— ❑ ❑ <br /> Dispenser—7/8 Dis enser— ❑ ❑ <br /> PAPERWORK INSPECTION Yes No N/A DaRoom <br /> te Done <br /> r12. <br /> Monitorin S stem Certification was completed within the past 12 months? 11-23-2010 <br /> Line Leak Detectors were tested/certified within the past 12 months? 11-23-2010 <br /> Spill bucket containment structure testingcompleted within the past 12 months? 11-23-2010 <br /> Line ti htness testin com leted within the re uired time frame?. Secondary containment tests completed within the required time frame? 2-11-2011 <br /> 14. Enhanced Leak Detection completed within the re uired time frame? <br /> 15. . Other required testing/maintenance was completed within required time frame? List test/maintenance items below. <br /> Describe Test/Maintenance:Air Quality St 27&30 2-17-2011 <br /> Describe Test/Maintenance: Li I Li <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facility em to ees received the required on-the-job training within the past ear? jF= <br /> ❑ <br /> 17. 1 Have all facili em to ees hired within the East 30 da s received the required on-the job trainin .? <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.unidocs.org 9/26/OS <br />