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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT [Name ity Name: Lodi Food& Liquor Inspection Date: � � ty Address: 1225 Lockford Street Ci of Designated UST Operator Conducting Inspection: ty Lodi, CA 95240 International Code Council Certification No.: Cit C Expiration Date: Signature: 2- Z-2.- fL. ___._..__.... _.. Phone: _ (916) 371-2380 ext. Item MONITORING PEL/ALARM HISTORY N/A=Not A lic�ble AN 1. Is the monitorin s stem owered on and in ro Der",o eratin mode? Yes No N/A 2. Is the monitor,- s -'not currentlyshowingan leak alarms? 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ Desi nated UST Operator? Attach a coDv othe alarm histo re ort/lo to this inspection orm. 4. Has each alarm for the revious month been res onded to aro riatel ? Ej UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:!f the annPer to item 4 was "Yes, skip to Item 6.Sumps where an alarm has occurred in the past month must be inspected tf a qualt led service technician has not responded to,and ro erl addressed,the cause othe alarm,Documentation ver !n a ro riate service should be attached re ort. Ye. No Yea Noto this f Sum Location: Sum Location: Sump Location: Sum Location: k" 6. Ares ill buckets containment structures fi-ee of water,debris,and hazardous substance? Yes No N/A Tank 1 ID-87 Tank 4 ID- Yes No N/A Tank 2 ID-91 Tank 5 ID- Tank 3 ID-DSL Tank d ID- 7. Are under-dispenser containment areas free of El water,debris,and hazardous substance? Yes No N/A Yes No N/A —Dispenser-1/2 Dis enser- Dispenser-3/4 Dis enser- Dispenser-5/6 Dis enser- Dispenser-7/8 Dispenser- El❑ 8. Leak detection isproperly located within under-dis enser containment. Yes No N/A Yes No N/A Dispenser- 1/2 Dis enser- Dispenser-3/4 1 El I Dispense - Dispenser-5/6 1 U I U Dispenser- Dis enser-7/8 Dispenser- 0j--0— PAPERWORK []PAPERWORK INSPECTION LYes I No I N/A Date Done 9. MonitoringSystem Certification was completed within the past 12 months? 11 23-2010 '%i;!�- 10. Line Leak Detectors were tested/certified within the past 12 months? +Hd11-23-2010 �(e.) H. Spill bucket containment structure testing completed within the past 12 months? I UV 0 1 11-23-2010 12. Line tightness testing completed within the required time frame? 13. SecondM containment tests completed within the required time frame? 1 2-11-2011 14. Enhanced Leak Detection completed within the required time frame? 15. Other required testing/maintenance was completed within required time frame? List test/maintenance items below. Describe Test/Maintenance:Air Quality St 27&30 1 U 2-17-2011 Describe Test/Maintenance: Li FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job training within the past ear? 17. Have all facili em to ees hired within the 2ast 30 days received the required on-the-job training.? 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