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UNDERGROUND STORAPE TAN SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Lodi Food & Liquor 1 ispection.Date: �: 22-110 Facility Address: 1225 Lockford Street ity- Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: t z International Code Council Certification No.: �� _ Expiration Date: J� j Signature: Phone: (916) 371/-2380 ext. N/A=Not A licable Item MONITORING PA !AL M HISTORY Yes No N/A 1. Is the monitoring system powered on and in proper o eratin m de? ❑ ❑ 2. Is the monitoring system not currently showing any leak alarms. ❑ ❑ 3. is the Alarm History Report/log for the previous month availabile,and has it been reviewed by the ❑ ❑ Desi-nated US"f Operator? (Attach a copy of the alarm history{report/log to this inspection form.) 4. Has each alarm for the previous month been res onded to a r riatel ? [01 ❑ MyAran'-92 7VUST SYSTEM INSPECTION 5. Are tank-top containment sumps free of water,debris, and hazardous substance? Note:If the answer to Item 4 was "Yes,"skip 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 properly addressed, the cause of the alarm.Documentation veri in a,ppropt iate service should be attached to this report. Ye! No Ye! Sump Location: El El Sump Location: Q. ❑ Sump Location: ❑ ❑ ,a Sump Location: ❑ ❑ _- 6. Arespill buckets(containment structures) free of water,debris and hazardous substance? Yes No N/A Yes No N/A Tank 1 ltd-S7 ----- C El Tank 4 ID- ❑ El F-1 EF Tank 2 1D-91 ------- ❑ El i a k 5 ID-- -- El Tank3ID-DSL ------ ❑ [1 la k(iID- ❑ ❑ C-1 7. Are under-dispenser containment areas free of water,debris, arid hazardous substance? Yes No N/A Yes No N/A --Dispenser-_l l2 Ey ❑ ❑ —Dispenser- ❑ ❑ Dispenser_3/11 ❑ ❑ Dispense - ❑ ❑ 0 Dispenser--5/6 _ ❑ ❑ Dispenser- ❑ ❑ _❑ _Dispenser-7/8 _ [01=0 Di enser- ❑ ❑ ❑ 8. Leak detection is properly located within under-dis enser containment. Yes No N/A _ Yes No N/A Dispenser- 1/2 ❑ _❑_ Di penser- El El ❑ Dispenser-3/4 El ❑` IN ens er- ❑ ❑ ❑ Dispenser-5/6 ❑ ❑ Di penser- ❑ ❑ ❑ Dispenser 7/8D❑ ❑ r pen ser 0 El PAPERWORK INSPECTION Yes No N/A Date Done 9. Monitoring System Certification was completed within the pat 12 months? ❑ ❑ 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 n onths? E] 11-29-2011 11. Spill bucket(containment structure)testing completed within he ast 12 months? ❑ E] 11-29-2011 12. Line tightness testis m coMeted within the required time frau e? ❑ ❑ 13. Secondary containment tests completed within the required tii e frame? 2-11-2011 14. Enhanced Leak Detection completed within the required time frame? 1:1El 15. Other required testin7/maintenance was completed within required time frame? (List test/maintenance items below.) _ Describe Test/Maintenance: Air Quality St 27&30 _ ❑ ❑ 12-22-2011 Describe Test/Maintenance:❑ ❑ FACILITY EMPLOY I.L TR INING Yes No N/A 16. Have all facilit em to ees received the required on-the- .job_t-aining within the past ear? ❑ ❑ 17. Have all facility em loyees hired within the past 30 days rece ved the required on-the-job training.? ❑ ❑ Note: Explain any"No" answers in the"Comments"section on the Ilowing page. Those issues require corrective action from the UST owner/operator. UN-057- 1/2 wwwmnidocs.o_ 9/26/05