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1225 W. Lockeford St, Lodi, CA 95240 PR0231350 <br /> 11/23/2021 Program: UST <br /> PHOTO 7: <br /> 10/15/2021 designated operator(DO) monthly report has incorrect overfill revention test date <br /> *l� Underground Storage Tan Inspection R@port <br /> Designated Designated UST operator Visual ; <br /> Appendix XIII a. amu' <br /> Underground Storage Tank _ e <br /> Deslgnatac UST Operator Visual inspection Report <br /> AcILIT -- --_ ---_.-- - 10.TESTING AND MAINI�fJANC Y <br /> Date a <br /> Yes No NA performed <br /> CERS ID Y INFORM4 TIi_N ___ — —_ <br /> 10181313 ----- - Inspection Date 10!15 21 ❑ <br /> --- Has monitoring system cei ilfirauon been completed within the �a<: <br /> 11/25/20 <br /> li Facih--- _ 12 months? leted within the past <br /> 11125120 <br /> Y NameLODI F - --- <br /> OOD&LIQUOR _ <br /> Facilit - _-----1 _-- d within Y Addre - IZip code 95240 Has spill container testing been co a wl In <br /> ss 1225 W LOCKEFORD Cary LODI 12 months? <br /> 11121/18 <br /> 2.DESIGN <br /> ATED Has overfill prevention equipment inspection been completed <br /> UST OPFR:17f1F INfORMA'r10M <br /> Name of Desi - - p,,,,; ,.r?. t the past 36 months — ❑ ❑ 2126/20 <br /> gnated UST operator Amy Winkler Has secondary containment testing been completed within the past <br /> ICC Certification 9951352-UC ,Certification Exp Date 312612023 36 months? ❑ ❑ <br /> 3.COMP __ - Has tank tightness testing b ted within required <br /> __ LIANCE IS _ ____ _ <br /> SUES -- ---- timeframes? ❑ ❑ <br /> Idenof ti�------._---------- - -- <br /> y y number att comp lance issues listed Has line tightness testing been within the require <br /> f� <br /> timeframes? ❑ El 71 <br /> ❑ ❑ ❑✓ <br /> Other Test/Maintenance: <br /> Other Test/Maintenance: <br /> - - — <br /> Other Test/Maintenance' — -- — Yes No <br /> — --- <br /> EMPLOYEAfi <br /> Have all individuals performing fa t;emFlrvee duties received tl le requ.red facility � ❑ <br /> Z3. training within the past'2'1c:ths? <br /> 13.CONfMBNTS <br /> This section may be u �Ec� c::r in nts or observation3 th a'. r 3 not current compliance <br /> t, deficiencies. <br /> 4.CERTIFICATION BY DEEM Nt 4TIcD UST OPEN t Tl ft <br /> ,. <br /> I hereby certify that the v',sual Inspection ed in compliance mitt Galitorn <br /> rovided <br /> Cc <br /> of Regulations,title 23,division 3,chapter 16,section 2716 and all information provid <br /> herein is accurate. I <br /> Designated UST operator Signature_ _ _-._ Date Inspection Report Pro ' <br /> 1011512' I <br /> Environmental Reporting System,ICC=Internation i <br /> ' of Applicable,UDC=Under-Dispenser Containm <br /> Storage Tank <br /> All answers marked`No"must be described by the designated UST operator in Section 3. <br /> P <br /> VICKY VANG-LEE, REHS Page 7 of 8 <br />