Laserfiche WebLink
® UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> FacilityName: Lodi Food & Liquor Inspection Date: Z — O 3 <br /> Facility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> International Code Council Certification No.: <br /> �� Expirationone: Date: tZ 2 2_/ <br /> Signature: Ph <br /> " (916) 371-2380 ext. <br /> ItemN/A=Not A licable <br /> MONITORING PANEL/ALARM HISTORY Y s No N/A <br /> 1. Is the monitorin s stem owered on and in proper o eratin mode? F-1 ❑ <br /> 2. Is the monitorin s stem not current! showing an 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 c9py o the alarm history re ort/lo to this ins ection form) <br /> 4. Has each alarm for the previous month been responded to a ro riatel ? ❑ ❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top containment sumps free of water,debris,and hazardous substance? Note:if the ansiver to Item 4 was 'Yes."skip <br /> to!tern 6. Sumps inhere an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and <br /> pro eraddressed.the cause of the alarm.Documentation veri in a ro riate service should be attached to this report, <br /> Yei No Ye! No <br /> Sum Location: ❑ ❑ Sump Location: ❑ ❑ <br /> Sump Location: <br /> El ❑ ,' Sump Location: ❑ ❑ <br /> 6. Are spill buckets(containment structures)free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Tank 1 ID—87 ❑ El Tank 4 ID— E] ElTank 2 ID— El Tank 5 ID—❑ El ElTank 3 ID—DSL ❑ Tank 6 ID— ❑ ❑ <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? <br /> Yes No N/A Yes No N/A <br /> Dispenser— 1/2 ❑ ElDis enser— 11 ❑ <br /> Dispenser—3/4 ❑ ❑ Dis enser— El ElDis enser—5/6 ❑ ❑ Dis enser— El F1Dis enser—7/8 R ❑ ❑ Dispenser— 10 ❑ <br /> 8. Leak detection is properly located within under-dis enser containment. <br /> Yes No N/A Yes No N A <br /> Dispenser— 1/2 <br /> Dispenser—3/4 ❑ ❑ Dispenser— ❑ I]❑ ❑ <br /> Dispenser—5Dis enser— 1:1 El/6 ❑ ❑ 21 <br /> Dispenser—7/8 Dispenser— El ❑ <br /> ❑ 10:1 Dispenser— ❑ El <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the past 12 months? <br /> Ij 10. Line Leak Detectors were tested/certified within the ast 12 months? F-1 11-29-2011 <br /> 11. Spill bucket(containment structure)testingcompleted within the past 12 months? ❑ ❑ 11-29-2011 <br /> 12. Line tightness testingcompleted within the required time frame? ❑ ❑ 11-29-2011 <br /> 13. Seconda containment tests completed within the required time frame? <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ ❑ 2-11-2011 <br /> 15. Other required testing/maintenance was completed within required time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance:Air Quali St 27&30 <br /> Describe Test/Maintenance: '� ❑ ❑ 12-22-2011 <br /> FACILITY EMPLOYEE TRAINING Yes No N/A <br /> 16. Have all facilityemployees received the required on-the-'ob trainin within the past ear? El <br /> 17. Have all facili em loyees hired within the ast 30 days received the re uired on-the-job trainin .? <br /> Note: Explain any"No"answers in the"Comments"section on the following page. Those issues require corrective action fr❑orn <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidoes.org <br /> 9/26/OS <br />