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n UNDERGROUND STORAGE TANK SYSTEM P 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: K International Code Council Certification No.: � J Expiration Date: (2—_2,Z� / 21 Signature: . _ Phone: (916) 371-2380 ext. N plicabie Item MONITORING PANEL/ALARM HISTORY Yes No N/A 1. Is the monitoring system powered on and in proper operating mode? 0 ❑ ❑ 2. Is the monitoring system not currently showing any leak alarms? t ❑ ❑ 3. Is the Alarm History Report/log for the previous month avail ble,and has it been reviewed by the ❑ ❑ Designated UST Operator? (Attach a copy o the alarm history report/logreportllog to this ins ection form.) 4. Has each alarm for the 1revious month been responded to appropriately? ❑ ❑ UST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water, debris,and hazardous substance? Note:if the answer to Item 4 Inas "Yes."skip to/tem 6. Sumps inhere 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 o the alarm.Documentation verifying appro griale service should be attached to this report. Yes NoYes No Sum Locat' �y` El El �� S m Location: Sump Location: ❑ I ❑ Symp Location: ❑ ❑ 6. . Ares ill buckets(containment structures)free of water,debri and hazardous substance? Yes No N/A Yes No N/A Tank 1 ID—87 rV1 ❑ ❑ r nk 4 ID— ❑ ❑ Tank 2 ID—91 ❑ ❑ Tank 5 ID— ❑ ❑ Tank 3 ID-DSL ❑ 1 ❑ Tank 6 ID— ❑ ❑ 7. Are under-dispenser containment areas free of water,deb.-is,and hazardous substance? Yes I No I N/A Yes No N/A Dispenser— 1/2 F3 11:1 1 [ D s enser— ❑ ❑ Dispenser—3/4 D Spenser— ❑ ElDispenser—5/6 ❑ r] D spenser— ❑ ❑ Dispenser—7/8 13 ❑ I D spenser— ❑ ❑ 8. Leak detection is properly located within under-dispenser con ainment. Yes I No I `J/A Yes No N/A Dispenser— 1/2 1h I ❑ I ❑ Dspenser— ❑ ❑ Dispenser—3/4 El ❑ D spenser— ❑ ❑ Dispenser—5/6 NJ ❑ I ❑ D spenser— ❑ ❑ Dispenser—7/8 N ❑ ❑ D spenser— ❑ ❑ 777 PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the pa t 12 months? ❑ ❑ 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 nths? ❑ ❑ 11-29-2011 IL Spill bucket(containment structure)testing completed within he past 12 months? ❑ ❑ 11-29-2011 12. Line tightness testing completed within the required time fram ? ❑ ❑ 13. Secondary containment tests completed within the required ti e frame? ❑ ❑ 2-11-2011 14. Enhanced Leak Detection completed within the required time ame? ElElhi 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 Al 10 12-22-2011 Describe Test/Maintenance: I ❑ I ❑ FACILITY EMPLOYEE TRAINING Yes No N/A 16. Have all facility employees received the required on-the-job triining within the past ear? IMZ ❑ ❑ 17. Have all facility employees hired within the past 30 da s received the required on-the-'ab 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.unidoes.org 9/26/05