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0 0 <br /> UNDERGROUND STORA E TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> k <br /> Facility Name: Lodi Food & Liquor hispection Date: IL,, 2— -2— <br /> Facility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: Expiration Date: , a -- <br /> Signature: Phone: (916) 371-2380 ext. <br /> N/A=Not Applicable <br /> Item MONITORING PANEL/ALA M HISTORY Yes No N/A <br /> 1. Is the monitoringsystem powered on and in proper operating m de? ❑ ❑ <br /> 2. Is the monitorings stem not currentl showin an leak alarms. ❑ ❑ <br /> 3. Is the Alarm History Report/log for the previous month availabl ,and has it been reviewed by the ❑ ❑ <br /> Designated UST Operator? (Attach a copy of the alarm history report/logto this ins ection orm.) <br /> 4. Has each alarm for the previous month been responded to a ro riately? ❑ I ❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazat dous substance? Note:If the ansiver to Item 4 was "Yes,"skip <br /> to Item 6.Sumps where an alarm has occurred in the past month must be in petted if a qualified service technician has not responded to, and <br /> properly addressed,the cause of the alarm.Documentation verifying appropri,Ve service should be attached to this report <br /> Ye! No 3 Ye, No <br /> Sum Location: El ay, Su Location: <br /> ❑ ❑ <br /> Sump Location: El El x: SuMp Location: F-1 ❑ <br /> 6. Ares ill buckets(containment structures)free of water,debris, ind hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID-87 ❑ ❑ Tan 4 ID- ❑ ❑ <br /> Tank 2 ID-91 ❑ ❑ Tan-5 ID- _ ❑ ❑ <br /> Tank 3 ID-DSL ❑ I ❑ Tamr,6 ID- ❑ ❑ <br /> 7. Are under-dispenser containment areas free of water,debris,an hazardous substance? <br /> es I No N/A I Yes I No N/A <br /> Dispenser- 1/2 ❑ ❑ I Dis enser- ❑ I ❑ <br /> Dispenser-3/4 ❑ ❑ Dispenser- ❑ ❑ <br /> Dispenser-5/6Etffi <br /> Dispenser- El El 4- <br /> Dispenser-7/8 Dispenser- ❑ ❑ <br /> 8. Leak detection is properly located within under-dis enser conta nment. <br /> Yes I No N/A I Yes No I N/A <br /> Dispenser- 1/2 M I ❑ I ❑ Dis enser- ❑ I ❑ <br /> Dispenser-3/4 ❑ ❑ Dispenser- ❑ ❑ <br /> Dispenser-5/6 ❑ ❑ Dispenser- ❑ ❑ ly <br /> Dispenser-7/8 ❑ ❑ Dispenser-777777�7- <br /> ❑ ❑ <br /> PAPERWORK INSPECTION Yes I No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? 1 ❑ 1 ❑ 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? 1 ❑ 1 ❑ 11-29-2011 <br /> 11. Spill bucket(containment structure)testing completed within thpast 12 months? ❑ El11-29-2011 <br /> 12. Line tightness testingcompleted within the required time frame ❑ Li [Q <br /> 13. Secondary containment tests com leted within the re uired tim frame? El—. <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ I ❑ <br /> 15. I Gr- <br /> Other required testing/maintenance was completed within required time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance:Air Quality St 27&30 1 K I 71-F <br /> 12-22-2011 <br /> Describe Test/Maintenance: I El 11-11 <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facility employees received the required on-the-job tra ning within the past year? ❑ ❑ <br /> 17. Have all facili employees hired within the past 30 da s receiv d the required on-the-'ob trainin .? ❑ ❑ <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 /> LIN-057-1/2 www.unidoes.org 9/26/05 <br />