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"N <br /> z UNDERGROUND STORAGE TANK SYSTEM <br /> ` IGNATED UST OPERATOR MONTHLY INSPECTION REPORT <br /> �ty Name: Y <br /> Lodi Food & Liquor Inspection Date: <br /> x <br /> acility Address: 1225 Lockford Street City: Lodi, CA 95240 <br /> Name of Designated UST Operator Conducting Inspection: V4- Z <br /> International Code Council Certification No.: � Expiration0(to7�2�U(� Date: � f Z� l 3 <br /> Signature: Phone: <br /> (916)371-2380 ext. <br /> N/A=Not A plicable <br /> Item MONITORING PANEL/ALARM HISTORY Yes o N/A <br /> 1. Is the monitoring system powered on and in ro er o eratin mode? ❑ ❑ <br /> 2. Is the monitoring system not currently showing any leak alarms? ❑ ❑ <br /> 3. Is the Alarm History Report/log for the previous month available,and has it been reviewed by the ❑ <br /> Desi rated UST Operator? Attach a copy o the alarm history report/logreponllog to this inspection orm. <br /> 4. Has each alarm for the revious month been res onded to aippronriate1 ? ❑ ❑ <br /> UST SYSTEM INSPECTION <br /> 5. Are tank-top contaimnent sumps free of water,debris,and hazardous substance? Note:If the answer to Item 4 ivas "Yes,"skip <br /> to Rem 6. Sumps where an alarm has occurred in the past month must be inspected if a qualified service technician has not responded to, and <br /> properly addressed,the cause af the alarm.Documentation veri in a ro riate service should be attached to this report. <br /> Yes No Ye; No <br /> Sum Location: <br /> ❑ Sum Location: ❑ EJ <br /> Location: ❑ ❑ Sum Location: <br /> 6. Ares ill buckets(containment structures)free of water,debris,and hazardous substance? ❑ ❑ 3 <br /> Yes No N/A Yes No N/A <br /> Tank I ID—87 ❑ ❑ Tank 4 ID— ® ❑ El <br /> 2 ID—91 ❑ BIT <br /> Tank 5 ID— ❑ ❑ El <br /> 3 ID--DSL ❑ Tank 6 ID= _ ❑ ❑ <br /> 7. Are tinder-dispenser containment areas free of water,debris,and hazardous substance? <br /> El <br /> Yes No N/A Yes No N/A <br /> Dispenser— 1/2 10 ❑ Dis enser— 1:1 ❑ ❑ <br /> Dis enser—3/ ❑ ❑ Dis enser— El ❑ 1:1Dis enser—5/66 ❑ ❑ Dis enser— ❑ ❑ E]Dis enser—7/8 ❑ ❑ Dispenser— ❑ ❑ E]8. Leak detection is properly located within under-dis enser containment. <br /> Yes No N/A Yes No N/A <br /> Dispenser— 1/2 ❑ Dispenser— ❑ ❑ ❑ <br /> Dispenser—3/4 ❑ ❑ Dispenser— ❑ ❑ El <br /> —5/6 ❑ ❑ Dispenser— ❑ Li El <br /> 7/8 ❑ ❑ Dispenser— <br /> ❑ ❑ ❑ <br /> PAPERWORK INSPECTION Yes No N/A Date Done <br /> 9. Mollitorina S stem Certification was completed within the .past 12 months? ❑ ❑ 11-29-2011 <br /> 10. Line Leak Detectors were tested/certified within the past 12 months? LJ El 11-29-2011 <br /> 11. Sill bucket(containment structure)testin completed leted within the ast 12 months? ❑ ❑ 11-29-2011 <br /> 12. Line tightness testingcom leted within the required time frame? I ❑ ❑ <br /> 13. Secondar containment tests completed within the re uired time frame? ❑ ❑ 2-11-2011 <br /> 14. Enhanced Leak Detection completed within the required time fi-ame? ❑ ❑ <br /> 15. Other required testing/maintenance was completed within required time frame? (List est/nwintenance items below.) <br /> Describe Test/Maintenance:Air Quak St 27&30 ❑ Uj 2-17-2011 <br /> Describe Test/Maintenance: ❑ ❑ <br /> Cj <br /> as ry x� Vii. <br /> FACILITY EMPLOYEE TRAINING <br /> 16. Have all facility employees received the required on-the-job'trainin within the past ear? Ye No N/A <br /> 17. Have all facilit em to ees hired within the ast 30 days received the required on-the-'ob training.? IE] <br /> El <br /> Explain any"No" answers in the"Comments"section on the following page. Those issues require corrective action from <br /> the UST owner/operator. <br /> UN-057-1/2 www.unidocs.org 9/26/05 <br />