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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR M NTHLY INSPECTION REPORT <br /> Facility Name: Lodi Food & Liquor Inspection Date: <br /> Facility Address: 7 �7 <br /> 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: <br /> 1 �vlrz <br /> International Code Council Certification No.: ��Da <br /> �/ Expiration Date: J <br /> Signature: /O `��/4.? <br /> Phone: (916) 371-2380 ext. <br /> Item MONI G PANEL/AL RM HISTORY N/A=Not A licable <br /> I. Is the monitnrincy suet,m owered on and in proper opeiating operatingode? Yes No N/A <br /> 2. Is the monitoring s stem not currently showing any leak alar s? <br /> 3. Is the Alarm History Report/log for the previous month availa le,and has it been reviewed b the ❑ ❑ <br /> Desi rated UST Operator? (Attach a copy o the alarm histol re ort/log to this inspection form.) El <br /> 4. Has each alarm for the previous month been responded to app o riatel ? <br /> El ❑ <br /> UST SYSTEM INSP CTION <br /> 5. Are tank-top containment sumps free of water,debris,and haz irdous substance? Note:If the answer to Item 4 was ••Yes, skip <br /> to Item 6. Sumps where an alarm has occurred in the past month must be juspected if a qualified service technician has not responded to, and <br /> roperly addressed,the cause a the alarm.Documentatton very in a ro late service should be attached to tills report. <br /> Ye! No Ye! No <br /> Sum Location: ❑ ❑ Su Location: ❑ El <br /> Location: ❑ ❑ , Su. Location: ❑ ❑ <br /> 6. Are spill buckets(containment structures)free of water, debris and hazardous substance? <br /> Yes No N/A <br /> Tank 1 ID-87 ❑ ❑ Ta k41D— <br /> Yes No N/A <br /> Tank 2ID-91 _ ® ❑ ❑ ar k5ID— ❑❑ ❑ ❑� <br /> _Tank_3 ID—DSL ❑ ❑ Ta k 6 ID— ❑ El ❑ <br /> 7. Are under-dispenser containment areas free of water, debris, and hazardous substance? <br /> Dis enser— 1/2 Yes No N/A Yes No N/A <br /> ❑ ❑ Dis' enser— ❑ ❑ ❑ <br /> Dispenser—3/4 ❑ ❑ Dis enser— 11 ❑ ❑ <br /> Dis enser—5/6 ❑ ❑ Dispenser— 1:1 ❑ ❑ <br /> Dis enser—7/8 10p❑ Dispenser— ❑ ❑ <br /> 8. Leak detection is properly located within under-dispenser conta nment. ❑ <br /> Dis enser— 1/2 <br /> Yes No N/A Yes No N/A <br /> 1:1 El Dis enser— ❑ El EJDis enser—3/4 <br /> Dispenser—5/6 ❑ ❑ Dis lenser— ❑ ❑ ❑ <br /> F1 El enser— <br /> Dispenser—7/8 ❑ ❑ ❑ <br /> Dispenser— <br /> PAPERWORK <br /> ispenser—PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitoring System Certification was completed within the ast 2 months? <br /> 10. Line Leak Detectors were tested/certified within the ast 12 mo 'ths? ❑ ❑ 11-29-2011 <br /> 11. Sill bucket(contaimnent structure) -stingcompleted within th past 12 months? ❑ ❑ 11-29-2011 <br /> 12. Line tightness testingcompleted within the required time frame? 1-1 ❑❑ ❑ 11-29-2011 <br /> 13. Secondary containment tests completed within the required time frame? <br /> 14. Enhanced Leak Detection com leted within the required time fra e? O ❑❑ ❑ 2-11-2011 <br /> 15. Other required testing/maintenance was completed within requir d time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance:Air Quality St 27&30 <br /> Describe Test/Maintenance ❑ ❑❑ ❑ 12-22-2011 <br /> FACILITY EMPLOYEE TRAINING <br /> 16. Have all facility em loyees received the required on-the-job train ng within the ast ear? Ye No N/A <br /> 17. Have all facility em loyees hired within the past 30 days receive the re uired on-the job training.? <br /> ❑ ❑ <br /> Note: Explain any"No"answers in the"Comments"section on the folio in ❑ ❑ <br /> the UST owner/operator. g page. Those issues require corrective action from <br /> UN-057-1/2 www.unidoes.org <br /> 9/26/OS <br />