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AWP�DesignAWnderground Storage Tank (U <br />Monthly Visual Inspection Checklist <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: <br />.Facility Address: 500 WEST HOSPITAL ROAD <br />City FRENCH CAMP Zip Code: CA 95231 <br />Designated UST Operator Conducting the Inspection: JESSE BERUMEN <br />Internation de Council ertification 8014628 -UC Ex iration Date: 7/25 0 i0 <br />Si atur . Phone: ( 209 ) 367-4800 <br />Y = <br />Item MONITORING PANEL / ALARM HISTORY _ <br />1 Monitoring system is powered on and in proper oper2EEy2 mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by; the <br />Design <br />aced UST Operator. Attach a copy of the alarm history rep og to this Lrm if availa <br />4 Each alarm for the previous month has been responded to a ro riatel . <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a - List all tank -top sumps where alarms occurred in the past month: <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a quaked service technician <br />' properly addressed, the cause of the alarm. Attach documentation verging appropriate service to this report. <br />:ate <br />Note: Any answer of '-IN" snoula De expiaineu In LIIe cvInlllcui bccuw1 URI we ay.,v...s y..F,., .......� •_.. - y. --- <br />follow-up action. M, <br />Page 1 of 2 <br />Noueilber 2004 <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection ofstimps is only re uired in sumps where an alarm has occurred in the past month or which there :s no service record <br />Y N <br />Sum Location: INE S X Sum Location: <br />Y N' <br />Sum Location: PIPINGS X Sum Location: <br />Sum Location: Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Y N NA <br />Tank 1— Contents: FILL BUCKET X Tank 3 — Contents: <br />X <br />Tank 2 — Contents: X Tank 4 —Contents: <br />—2i- <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located ro erl . <br />Y N NA <br />Y N NA <br />Dispenser I / 2 X Dispenser 9 /10 <br />X <br />Dispenser 3 / 4 X Dis enser 11 / 12 <br />X <br />Dispenser 5 / 6 X Dispenser 13 114 <br />X <br />Dispenser 7 / 8 X 'Dispenser 15 / 16 <br />X <br />PAPERWORK INSPECTION Y N NA <br />DATE DONE <br />9 <br />Monitoringsystem certification has been completed within'past 12 months. X <br />08/22/2014 <br />10 <br />Secondarycontainment tests have been completed within the required timeframe. X <br />03/22/2012 <br />11 <br />Spill containment structure (bucket)testingwas completed within the past year. X <br />08/22/2014 <br />12 <br />Tank tightness testingwas completed within required timeframe. X <br />-------� <br />13 <br />Line tightness testingwas completed within required timeframe. SEE COMMENTS X <br />08/22/2014 <br />14 <br />Other required testing/maintenance was completed within required timeframe. <br />Test: i. , , ° 989. n . ' ° nta�e nein 8bld'4p X <br />Test/Maintenance: <br />03/22/2012 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facility employees have received the required on-the-job training within thepast year. <br />X <br />16 <br />All facili em to ees hired within the past 30 !lays have received the required grrthe- ob trainin . <br />Note: Any answer of '-IN" snoula De expiaineu In LIIe cvInlllcui bccuw1 URI we ay.,v...s y..F,., .......� •_.. - y. --- <br />follow-up action. M, <br />Page 1 of 2 <br />Noueilber 2004 <br />