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i <br />Designate Underground Storage Tank (US Operator <br />Monthly Visual Inspection Cheeky <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: <br />I <br />Facility Address: 500 WEST HOSPITAL ROAD <br />City: <br />FRENCH CAMP Zip Code: CA 95231 <br />Designated <br />UST Operator Conducting the Inspection: JESSE BERUMEN <br />International ode ouncil Cert cation 8014628 -UC Exp ration Date: 7/25/2015 <br />Signature:, Phone: ( 209 ) 367-4800 <br />V = Yes, N No, NA = Not <br />Item MONITORING PANEL / ALARM HISTORY Y N <br />I <br />Monitoring system is powered on and in proper operating mode. <br />x <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />x <br />R <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Opemtor. (Attach a co ff of the alarm history reportllog to thisform if available.) <br />x <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />x <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />x <br />5a <br />List all tank -top sumps where alarms occurred in the past month: <br />1�month 7 otJ�;ni�s where an alarm occurred in the mon - " d inspected unless a qualified service technician responded <br />properly addressed the cause of the alarm Attach documentation verging appropriate service to this report <br />1 s52 inspection is re fired, record results in item 6 below. <br />UST SYSTEM INSPECTION <br />to, <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection a <br />f sumps is only requi in sumps where an alarm has occurred in the past month or which there is no service record <br />Y N <br />Y N, <br />Sump Location: TURBINE SUMP x Sump Location: <br />Sump Location: PIPING SUMP x 6hfmp Location: <br />i[Sump <br />Sump Location: Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />/ I Y N NA <br />Y N <br />Tank 1- Contents: FILL BUCKET X Tank 3 — Contents: <br />-A <br />x <br />Tank 2 — Contents: x Tank 4 — Contents: <br />x <br />8 <br />Under-dis enser containment areas are free of water, debris, and hazardous substance. Sensors are located properly. <br />Y N NA <br />Y I N I NA <br />DiVenser 1/ 2 X Dispenser 9 /10 <br />x <br />Dispenser 3 4 X Dispenser 11 12 <br />x <br />Dispenser 5 6 X Dis <br />penser 13 14 <br />x <br />Dgenser 7 8 x DisCenser 15 16 <br />x <br />IMME <br />PAPERWORK INSPECTION Y N NA <br />DATE DONE <br />9 <br />Monitoring system certification has been c2�mpleted within past 12 months. x <br />08/22/2014 <br />10 <br />Secondary containment tests have been completed within the required timeframe. x <br />03/22/2012 <br />11 <br />Spill containment structure (bucket) testing was completed within the past year. x <br />08/22/2014 <br />12 <br />Tank ti tress testing was completed within required timeframe. x <br />— ------- — — <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS X <br />08/22/2014 <br />14 <br />Other reguired testing/maintenance w completed within required timeframe. <br />Test: �W iooi4" x <br />03/22/2012 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />'facility <br />Y N INA <br />15 <br />A ff em to have received the required on-thejob training within the ean- <br />x <br />16 <br />All facility em 12yees hired within the past 30 qays have received the required o6-the-job'tEainin . <br />Note: Any answer of "N" should be explained in the comment section on the following "page, and will require <br />follow-up action. <br />Oil <br />E <br />Page 1 of 2 November 2004 <br />