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0 0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Lodi Food & Liquor <br /> Inspection Date: I -Z�F t <br /> Facility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: Z S- <br /> (T 2- Lk-c- Expiration Date: <br /> Signature: Z_ Z-Z_ e <br /> - Phone: (916) 37 1-2380 ext. <br /> Item MONITORING PANEL/ALARM HISTORY licable <br /> 1. Is the monitorin system powered on and in proper operating mode? Yes No N/A <br /> 2. Is the monitoring system not currentl showin any leak alarms? ❑ ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ ❑ <br /> Desi nated UST Operator? (Attach a co o the alarm histo re ort/lo to this ins ection orm.) El EJ <br /> 4 Has each alarm for the revious month been responded to a ro riatel ? <br /> ❑ ❑ <br /> 5. Are taUST SYSTEM INSPECTION <br /> nk-top containment sumps free of water,debris,and hazardous substance? Note:if the ans,ver to Item 9 was Yes,"ski . <br /> 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 <br /> properly addressed,the cause of the alarm.Documentation o ri in a ro riate service should be attached to this report. <br /> Yes No <br /> Sump Location: Yes No ` <br /> ❑ Sum Location: <br /> Sum Location: ❑ ❑ " <br /> 6. Ares ill buckets(containment structures)free of water,debris,ana hazardous substance? ❑ ❑ <br /> Tank 1 ID—87 Yes No N/AEl ❑ Tank 4 ID— Yes No N/A <br /> Tank 2 ID—91 F-1 El 5 ID— El ❑ ❑ <br /> Tank 3 ID—DSL El EDTank 6 ID— 1:1 E] El <br /> El7. Are under-dis enser containment areas free of water,debris,and hazardous substance? EJ ❑ <br /> Dispenser— 1/2 <br /> Yes No N/A Yes No N/A <br /> ® ❑ ❑ Dispenser— <br /> Dispenser—3/4 ❑ ❑ ❑ <br /> ® ❑ El El7 <br /> Dispenser— /6 Dispenser— ❑El enser— El ❑ ❑ <br /> Dispenser—718 ® ❑ El Dispenser— El El El8. Leak detection is ro erl located within under-dis enser containment. <br /> Yes No N/A Yes No N/A <br /> Dispenser— 112 ❑ ❑ Dis enser— ❑ ❑ 1:1Dis enser—314 ® ❑ Dis enser— ❑ ❑ ❑ <br /> Dispenser-5/6 ® ❑ Dispenser- ❑ ❑ ElDispenser-7/8 ® ❑ ❑ Dispenser- ❑ ❑ ❑ <br /> 9. MonSystem <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> Monitoring S stem Certification was completed within the past 12 months? ❑ 0 ❑ 11-23-2010 �d;V—''( <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ❑ 11-23-2010 <br /> 1 1. Sill bucket(containment structure)testingcompleted within the ast 12 months? ❑ © ❑ 11-23-2010 <br /> 12. Line tightness testing completed within the required time frame? ❑ ❑ ❑ <br /> 13. Secondary containment tests completed within the required time frame? ❑ ❑ 2-11-2011 <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ ❑ <br /> 15. Other re uired testing/maintenance was completed within re uired time frame? (List test/maintenance items below) <br /> Describe Test/Maintenance: Air Quality St 27&30 9Z I ❑ ❑ 2-17-2011 <br /> Describe Test/Maintenance: ❑ ❑ ❑ <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facility employees received the required on-thejob trainiM within the past ear? ❑ 1 ❑ <br /> 17. Have all facili employees hired within the ast 30 days received the required on-the- training.? ❑ <br /> Note: Explain any"No"answers in the"Comments" section on the following page.Those issues require corrective action from <br /> the UST owner/operator. <br /> LJN-057-1/2 www.unidocs.org 9/26/05 <br />