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i Designated Underground Storage Tank jsqOpera Monthly Visual Inspection Checklist Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: 16i Facilt Address: 500 WEST HOSPITAL ROAD City: FRENCH CAMP Zip Code: CA 95231 Designated UST Operator Conducting the Inspection: JESSE BERUN InternationalgQ Council Certification 8014628-UCEx iration Date: 7/25/ Signature/ Phone: 209 367-4800 Item MONITORING PANEL / ALARM HISTORY 1 Monitoring system is powered on and in proper operating mode. 2 Monitoring system is not currently showing any alarms or warnings. 3 Alarm history report/log, for the previous month is available, and has been reviewed by tt Designated UST Operator. Attach a cqpy o the alarm history report/loreponft to this orm i' 4 Each alarm for the previous month has been responded to appropriately. 5 Sensors located in tank -top containment sumps have not alarmed in the past month. 5a - List all tank -top sumps where alarms occurred in the past month: Note: Sumps where an alarm has occurred in the past month must be inspected unless a quaked service techj properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. I su ins ectton is ;Sired, record results in item 6, below. UST SYSTEM INSPECTION 6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located prk.r Note: Visual inspection of sums is only requi in su s where an alarm has occurred in the past month for which there is no se Y N Y Sump Location: TURBINE SUMP X Sump Location: Sump Location: PIPING SUMP X Sump Location: Sump Location: I Sump Location: 7 Spill containment structures are free of water, debris, and hazardous substance. Y N NA 'Y Tank 1— Contents: FILL BUCKET X Tank 3 — Contents: Tank 2 — Contents: X Tank 4 — Contents: 8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located Y N NA Y Dispenser 1/ 2 X Dispenser 9 /10 Dis enser 3 / 4 X Dispenser 11 / 12 Dis enser S / 6 X Dispenser 13 / 14 Dispenser 7 / 8 X Dispenser 15 / 16 FACILITY EMPLOYEE TRAINING Y N NA 15 All facility employees have received the required on-the-'ob training within the past year. X 16 All facili em to ees hired within the past 30 da s have received the re u' on-the-'ob training. j X Note: Any answer of "N" should be explained in the comment section on the following page, and will req Wile y follow-up action. Page i of 2 November 2004 PAPERWORK INSPECTION Y N INA DATE DONE 9 Monitoring system certification has been completed within past 12 months. X 08/22/2014 10 Secondary containment tests have been completed within the required timeframe. X 03/22/2012 11 Spill containment structure(bucket) testing was completed within the past year. X 08/22/2014 12 Tank tightness testing was completed within required timeframe. X --__--------_ 13 Line tightness testing was completed within required timeframe. SEE COMMENTS X 08/22/2014 14 Other required testis maintenance was completed within required timeframe. Test. t�", . x 8�,:. a�.� , .. w.k ..,. "3122126,15 X 03/22/2012 Test/Maintenance: Test/Maintenance: FACILITY EMPLOYEE TRAINING Y N NA 15 All facility employees have received the required on-the-'ob training within the past year. X 16 All facili em to ees hired within the past 30 da s have received the re u' on-the-'ob training. j X Note: Any answer of "N" should be explained in the comment section on the following page, and will req Wile y follow-up action. Page i of 2 November 2004