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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: <br /> Facility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: , <br /> International Code Council Certification No.: ((0?�12�1�1 Expiration Date: <br /> OA/ t3 <br /> Signature: Phone: <br /> � (916) 371-2380 ext. <br /> N/A=NotA plicable <br /> Item MONITORING PANEL/ALARM HISTORY Yes o N/A <br /> 1. Is the monitoring system powered on and in proper operating mode? ❑ <br /> 2. Is the monitoring system not current!y showing any leak alarms? <br /> 3. Is the Alarm History Reportllog for the previous month available,and has it been reviewed by the <br /> Designated UST Operator? Attach a qqpy o the alarm history report/logreportllog to this ins ection orm. <br /> __AAHas each slat m for the 1 evious month been responded to aDnronriateI4 <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to lien;4 was "Yes, skip <br /> to!rein 6. Sumps where an alarm has occurred to the past month must be inspected tf a qua!led service technician has not responded to, and <br /> properly addressed,the cause o the alarm.Documentation vert in a ro riate service should be attached to this report. <br /> Ye' No Ye; No ' €` <br /> Sump Location: H Sump Location: ks <br /> Sump Location; El Sump 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 UT JLJ El Tank 4 ID— <br /> Tank 2 ID—91 EjTank 5 ID— <br /> T-ank-3-I13 -DSL- _ Tank Cs-ID_ ---- <br /> I El <br /> 7. Are under-dispenser containment areas free of water,debr s,and hazardous substance? <br /> Yes No N!A Yes I No N/A <br /> Dispenser— 1/2 Li Dispenser— <br /> Dispenser—3/4J,LiDis Dispenser— F1 I ET <br /> Dispenser—5/6 Dispenser— <br /> Dispenser—7/8 ;Dis enser— <br /> 8. Leak detection is properly located within under-dis enser containment. <br /> _YesJ No I N/A I i Yes No N/A <br /> Dispenser— 1/2 _H PDenser— <br /> Dispenser—3/4 Dispenser I El <br /> — <br /> Dispenser—516 Li Dispenser— [l <br /> Dispenser—7/8 Dispenser— El <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? 11-29-2011 <br /> 11. Spill bucket containment structure testing completed within the past 12 months?� 9 11-29-2011 <br /> 12. Line tightness testingcompleted within the required time frame? <br /> 13. Secondarycontainment tests completed within the re uired time frame? 3T2-11-2011 <br /> 14. Enhanced Leak Detection completed within the required tine frame? <br /> 15. Other required testing/maintenance was completed within re uired time frame? List test/ intenanceisbe . <br /> Describe Test/Maintenance:Air QualitySt 27&30 11Describe Test/Maintenance: <br /> FACILITY EMPLOYEE T AWING N/A <br /> 16. Have all facility employees received the required on-the-job'l,training within the past ear? <br /> 17. Have all facility em to ees hired within the 2ast 30 da s received the required on-the-•ob trainin .? <br /> Note: Explain any"No"answers in the"Comments"section on thelfollowing page.Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidocs.org 9/26/05 <br />