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i " 0 UNDERGROUND STOR IA,GE TANK SYSTEM DESIGNATED UST OPERATOR MQNTHLY INSPECTION REPORT F' Facility Name: Lodi Food & Liquor Inspection Date: Facility Address: //30 /2 1225 Lockford Street City: Lodi, CA 95240 Name of Designated UST of Conducting Inspection: z International Code Council Certification No.: Expiration Date: Signature: /3 Phone: (916) 371-2380 ext. ItemN/A=Not A ficable MONITORING P /A RM HISTORY Yes o N/A 1. Is the monitorin s stem owered on and in proper operating ode? El ❑ 2. Is the monitorin s stem not current] showingan leak alarms? ❑ ❑ 3. Is the Alarm History Report/log for the previous month availa le,and has it been reviewed by the ❑ ❑ Desi rated UST O erator? (Attach a copy of the alarm hnistory revortllog to this ins ection orm.) 4 Has each alarm for the revious month been res onded to a To riatel ? ❑ ❑ 1�_- •e y UST SYSTEM INSP CTION 5. Are tank-top containment sumps free of water,debris,and haz rdous substance? Note:If the ansiver to Item 4 was Yes,' skip to Item G. Swaps inhere an alarm has occurred in the past month must be nspected if a qualified service technician has not responded to,and pro erl addressed,the cause g�f the alarm.Documentation veri in a ro late service should be attached to this re ort. Yep No Yep No Sump Location: ❑ ❑ Su Location: ❑ ❑ `- Sum Location: ❑ ❑ ` . Su Location: ❑ ❑ 6. Ares ill buckets(containment structures)free of water,debris and hazardous substance? Yes No N/A Yes No N/All Tank I ID—87 ❑ Ta k 4 ID— ❑ ❑ ❑ Tank 2 ID—91 ❑ ❑ Tank 5 ID— _ ❑ ® ❑ Tank 3_11)—DSL -- ❑ ❑ Tar k 6 ID— ❑ ❑ ❑ 7. Are under-dispenser containment areas free of water,debris,and hazardous substance? Dispenser— 1/2 Yes No N/A Yes No N/A ❑ ❑ ❑ ❑ ❑ Dispenser—3/4 Dis enser— ❑ Ll Dis enser— ❑ ❑ ❑ Dispenser—5/6 ❑ [:1 Dis enser— ❑ ❑ ❑ Dispenser—7/8 ❑ ❑ Dis enser— ❑ ❑ ❑ 8. Leak detection is ro ert located within under-dis enser conta nment. Ye No N/A Yes No N/A Dispenser— 1/2 ❑ ❑ Dis enser— E] El ElDispenser—3/4 1:1 ❑ Dis enser— 1:1 1:1 ElDispenser—5/6 ❑ ❑ Dis enser— El El ❑ Dispenser 7/8 ❑ ❑ D sr enser— r°_x ❑ ❑ ❑ PAPERWORK INSPECTIONYes No N/A Date Done 9. MonitoringS stem Certification was completed within the past 2 months? 10. Line Leak Detectors were tested/certified within the past 12 mor ths? ❑ ❑ 11-29-2011 IL S ill bucket(containment structure)testin completed within th ast 12 months? El El11-29-2011 12. Line ti htness testin com leted within the required time frame? ❑ EJ El 11-29-2011 13. Secondary containment tests com leted within the required time frame? ❑ ❑ 2-11-2011 14. Enhanced Leak Detection completed within the required time frame?maintenance was completed ❑ El15. Other re uired testin within re uir d time frame? (List test/ aintenance items below.) Describe Test/Maintenanceality St 27&30 El 2-17-2011 Describe Test/Maintenance: ❑ ❑ FACILITY EMPLOYEE TRAI :ING 16. Have all facilityem to ees received the required on-the-'ob trai in within the past ear? Yes 17. Have all facility emee plo s hired within the ast 30 da s received the required on-the-•ob trainin .? ❑ ❑ ❑ Note: Explain any"No"answers in the"Comments"section on the follo ing page. Those issues require corrective action from the UST owner/operator. UN-057-1/2 www.unidocs.org 9/26/05