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UNDERGROUND STORAGE TANK SYSTEM <br /> DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> Facility Name: Lodi Food & Liquor <br /> Inspection Date: <br /> Facility Address: 1225 Lockford Street _ �� <br /> Name of Designated UST Operator Conducting Inspection: City. Lodi, CA 95240 <br /> tq�, <br /> International Code Council Certification No.: C'�itZ <br /> Signature: �11p��a Expiration Date: ®4:1S / <br /> Phone: (916) 371-2380 ext. <br /> Item MONITORINGN/A=Not A licable <br /> 1. Is the monitorin system powered on and in pro er o eratin rn dM HISTORY <br /> Yes No N/A <br /> 2. is the monitorin system not currently snowing any leak alarm ? ❑❑ ❑❑ <br /> 3. Is the Alarm History Report/log for the previous month availab e,and has it been reviewed by the <br /> Designated UST Operator? (Attach a co o the alarm histo re ort/lo to this ins ection form) <br /> ❑ ❑ <br /> 4. Has each alarm for the previous month been res onded to a r ratel ? <br /> ❑ ❑ <br /> UST SYSTEM 1 INNFk CTION <br /> 5. Are tank-top containment sumps free of water, debris,and hazardous substance? Nore:f dre answer to/ten,4 was <br /> to item G. Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and <br /> ro erl.,addressed,the cause o the alarm. Docunrentattar ver i in a pro r to service should be attached to this report. Yes,"skip <br /> Ye! No <br /> Sump Location: Ye! No `. <br /> Sump Location: El ❑ Z'11 "III <br /> � Su Location: ❑ ❑ <br /> .6. Are spill buckets(containment structures)free of❑ivater,debnsm nd haza d ❑ ❑ <br /> ou <br /> Yes No N/A <br /> s substance? <br /> Tank 1 1D–87 ❑ 1:1 Tan 4 ID– Yes No N/A <br /> Tank 2 ID–D ❑ ❑ Tan 5 ID– ❑ <br /> Tank 3 ID–DSEl El L❑ ❑ Tan 6 ID– <br /> 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? ED] ❑ <br /> Ye No N/A <br /> Dispenser– 1/2 Yes No N/A <br /> 01Disp Dispenser–❑ El ❑ <br /> Dispenser–3/4 ❑ ❑ Dis <br /> Dispenser–5/6 nser– <br /> ❑ ❑ <br /> ❑ <br /> ❑ ❑ Di- nser– ❑ ❑ ❑ <br /> Dispenser–7/8 ❑ ❑ Disnser– <br /> pe <br /> 8. Leak detection is properly located within under-dispenser containment. 101 ED] ❑ <br /> Yes No N/A <br /> Dispenser– 1/2 ❑ 11 Dis eser– Yes No N/A <br /> Dispenser–3/4 El ❑ Dis eser– F-1 1:1 1:1Dispenser–5/6 ser– <br /> F-1 ❑ El❑ ❑ Dispe <br /> Dispenser–7/8 ❑ ❑ Dispe ser– ❑❑ ❑❑ ❑❑ <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Monitorin System Certification was completed leted within the past 1 months? ❑ ❑ 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ❑ 11-29-2011 <br /> 1 1. Spill bucket(containment structure)testingcompleted within the ast 12 months? ❑ ❑ 11-29-2011 <br /> 12. Line tightness testing com leted within the required time frame? ❑ ❑ <br /> 13. Secondary containment tests completed within the required time ame? ❑ ❑ 2-11-2011 <br /> 14. Enhanced Leak Detection completed within the required time frame? ❑ ❑ <br /> 15. Other required testing/maintenance was com leted within required time frame? (List test/maintenance items below.) <br /> Describe Test/Maintenance.xi-r—Quality St 27&30 ❑ ❑ 12-22-2011 <br /> Describe Test/Maintenance <br /> FACILITY EMPLOYEE TRAINING <br /> 16. Have all facile employees received the required on-the-'Rb trainingwithin the past year? Yes No N/A <br /> 17. Have all facility employees hired within the ast 30 days received he required on-the-job trainin .? ❑ ❑ <br /> Note: Explain any"No"answers in the"Comments"section on the folio ing page. Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidoes.org <br /> 9/26/05 <br />