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s UNDER ROUND STORAGE TAN SYSTEM DESIGNATED UST OPERATOR MONTHLY INSPECTION REPORT Facility Name: Lodi Food & Liquor Inspection Date: <</ Z t,!�Z Facility Address: 1225 Lockford Street City: Lodi, CA 95240 Name of Designated UST Operator Conducting Inspection: CV4 Z_ International Code Council Certification No.: uC! Expiration Date: Signature: Phone: (916) 371-2380 ext. N/A=Not A>>licnble Item MONITORING PA EL LARM HISTORY Yes o N/A 1. Is the monitoring system powered on and in proper o to in ❑ ❑ 2. Is the monitorings stem not currently showing any leak alarms! R ❑ ❑ 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ ❑ Desi nated UST Operator? (Attach a copy of the alarm history report/logreportfigg to this inspectionform) 4. Has each alarm for the revious month been responded to a ro riatel ? ❑ ❑ UST SYSTEM INSPE TION [6. . Are tank-top containment sumps fi•ee of water,debris,and haze dous substance? Note:If the ansiver to Item 4 ivas "Yes,"skip to hem 6. Swaps where an alarm has occurred in the past month must be in ected if a qualified service technician has not responded to, and properly addressed,the arose o the alarm.Documentation vera in a ro ri to service should be attached to this report. Ye! N0 Ye! No Sump Location:_ ❑ ❑ Sum Location: ❑ Sum Location ❑ ❑ Sump Location: ❑ ❑ Are spil I buckets(containment structures)fi•ee of water,debris,4nd hazardous substance? Yes No N/A I Yes No N/A Tank 1 1 D-87 ❑ ❑ Tan 4 ID- ❑ ❑ ❑ �I Tank 2 ID-91 _ _ v ❑ ❑ Tank,5 ID- _ _❑ ❑ E-1 Tank 3 ID -DSL ❑ ❑ Tan' 6 ID- i ❑ I ❑ ❑ 7. Are under-dispenser containment areas free of water,debris,anq hazardous substance? _ Yes No N/A I es No N/A _Dispenser- 1/2 _ v ❑ ❑ Di—sr enser- ❑ I ❑ _❑_ Dispenser -3/4 ❑ ❑ Disr enser- ❑ ❑ 1 Dispenser-5/6 ❑ I Dis enser- ❑ ❑ ❑ Dispenser--7/8 Y1 ❑ ❑ Dispenser- ❑ ❑ ❑ 8. Leak detection is properly located within under-dispenser conte nment. _ Yes I No I N/A Yes No N/A Dispenser- 1/2_ ❑ Disr enser- ❑ ❑ ❑_ Dispenser-3/4 _ 12, ❑ ❑ Disr enser- ❑ ❑ _❑ Dispenser-5/6_ ❑ I ❑ Disr enser- ❑ ❑ ❑ Dispenser-7/8 [ff I ❑ I ❑ Dis enser- ❑ ❑ ❑ PAPERWORK INSPECTION Yes No N/A Date Tone 9. Monitoring System Certification was completed within the past 12 months? ❑ ❑ 11-29-2011 10. Line Leak Detectors were tested/certified within the past 12 months? ❑ ❑ 11-29-2011 11. Spill bucket(containment structure)testing completed within thpast 12 months? ❑ ❑ 11-29-2011 12. Line ti fitness testing completed within the required time frame ❑ ❑ 13. Secondary containment tests completed within the required time frame? ❑ ❑ 2-11-2011 14. Enhanced Leak Detection completed within the required time fi me? ❑ I ❑ 15. Other required testing maintenance was completed within requi ed time frame? (List test/maintenance items below.) Describe Test/Maintenance: Air Quality St 27&30 ❑ ❑ 12-22-2011 Describe Test/Maintenance: ❑ I ❑ - _ FACILITY EMPLOYEE TRAINING ING Yes No N/A 16. Have all facility employees received the required on-the-job tra'ning within the past year? ❑ ❑ 17. Have all facility employees hired within the est 30 days receiv d the required on-the-job training.? ❑ ❑ Note: Explain any"No" answers in the"Comments"section on the following page. Those issues require corrective action fi•om the UST owner/operator. UN-057-1/2 www.unidocs.org I 9/26/05