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UNDERGROUND STORAGE TANK SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Lodi Food & Liquor Inspection Date: Facility Address: 1225 Lockford Street City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: 'J� Of-DI F. /`� 1111 International Code Cou it ification No.: Z Expiration Date:C 2 ,2-2 -1 2_ Signature: Phone: (916)371-2380 ext. N/A=Not pi cabie Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. Is the monitoring system powered on and in proper operating mode? ❑ ❑ 2. Is the monitoring system not currently showing any 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 copy o the alarm history repolft report/loto this inspection form.) 4. Has each alarm for the reviousmonth been res onded to a ro riatel ? ❑ El UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 ivas"Yes,"skip to Item 6. Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and properly addressed,the cause of the alarm.Documentation veri in ap ro riate service should be attached to this report. Ye! 1No s Ye,, No Sump Location: ❑ I ❑ Sump Location: ❑ ❑ Sump Location: ❑ I ❑ Y., Sump Location: ❑ ❑ Are spill buckets(containment structures)free of water,debris,and hazardous substance? 6. ? Yes No N/A Yes No N/A Tank 1 ID-87 [j ❑ ❑ Tank 4 ID- ❑ ❑ Tank 2 ID-91 ❑ ❑ Tank 5 ID- ❑ ❑ Tank 3 ID-DSL ❑ Tank 6 1D- ❑ ❑ 7. Are under-dispenser containment areas free of water,debris, and hazardous substance? Yes No I N/A Yes No N/A Dispenser- 1/2 ❑ ElDispenser-1[ ❑ ❑ Dispenser-3/4 ❑ ❑ Dispenser- ❑ ❑ Dispenser-5/6 ❑ ❑ Dispenser- ❑ ❑ Dispenser-7/8 ❑ ❑ Dispenser- ❑ ❑ (� 8. Leak detection is properly located within under-dispenser containment. Yes I No I N/A Yes No I N/A Dispenser- 1/2 121 ❑ I Dispenser- ❑ ❑ Dispenser-3/4 ❑ ❑ Dispenser- ❑ ❑ Dispenser-5/6 ❑ I ❑ Dispenser- ❑ ❑ Dispenser 7/8 ❑ ❑ Dispenser ❑ PAPERWORK INSPECTION Yes No N/A Rate Done 9. Monitoring System Certification was completed within the past 12 months? Z I ❑ I ❑ 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 months? I ❑ I ❑ 11-29-2011- 11. Spill bucket(containment structure)testing completed within the past 12 months? ❑ I Q 11-29-2011 12. Line tightness testing completed within the required time frame? ❑ ❑ 13. Secondary containment tests completed within the required time frame? ( ❑ ❑ 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 ❑ ❑ 12-22-2011 Describe Test/Maintenance: FACILITY EMPLOYEE TRAINING Yes _No N/A 16. Have all facility employees received the required on-the-job training within the past ear? E9 ❑ ❑ 17. Have all facility employees hired within the past 30 da s received the required on-the-'ob train` .? ❑ ❑ 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.unidoes.org 9/26/05