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Ll <br />DesignalePUnderground Storage Tank US O erator <br />Monthly Visual Inspection Chec4st <br />Facility Name: <br />Facility Address: <br />SAN JOA UIN GENERAL HOSPITAL <br />500 WEST HOSPITAL ROAD <br />Date: <br />City: <br />FRENCH CAMP <br />Zip Code: CA 95231 <br />Designated USI <br />Operator Conducting the Inspection: JESSE BERUMEN <br />InternationqKC94e <br />Coun jl Certification 8014628 -UC <br />Expiration Date: 7/25/2015 <br />Signature: <br />4 <br />Phone:( 209 ) 367-4800 <br />Y = Yes, N = No, NA = Not,Applicable <br />Item <br />MONITORING PANEL / ALARM HISTORY <br />Y N NA <br />1 <br />Monitorings stem is powered on and in proper operating mode. <br />INMEM <br />X <br />2 <br />Monitorin system is not currently showing any alarms or warnings. <br />X' <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy o the alarm history report/reportoft to this ?rm i available. <br />$ <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 occurrej in the past month: kV UL, <br />-�k <br />Note: Sumps re an alarm has occurred in'ZpastAord must be inspected unless a quaked service technician responded to, and <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this report. <br />1 ins ction is re uired, record results in item 6, below. <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 of sumps is oral y required in sum s where an alarm has occurred in the past month or which there is no service record <br />Y N <br />Y N <br />Sum Location: TURBINE SUMP X <br />Sum Location: <br />Sum Location: PIPINGS X <br />Sum Location: <br />Sum Location: <br />Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N I NAT <br />Y N NA <br />Tank 1 — Contents: FILL BUCKET X I I I Tank 3 — Contents: <br />X <br />Tank 2 — Contents: I I X I Tank 4 —Contents: <br />T TX <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located 3roperly. <br />Y N NA <br />Y N INA <br />Dispenser 1/ 2 X Dispenser 9110 <br />X <br />Dispenser 3 / 4 X Dispenser 11 / 12 <br />X <br />Dispenser S / 6 X Dis eraser 13 / 14 <br />X <br />Dis eraser 7 / 8 X Dis eraser 15 / 16 <br />X <br />sum IN <br />PAPERWORK INSPECTION Y N NA <br />OM <br />DATE DONE <br />9 <br />Monitorin system certification has been completed within past 12 months. X <br />08/16/2013 <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 />08/16/2013 <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 />08/16/2013 <br />14 <br />Other required testis maintenance was completed within required timeframe. <br />Test: 14r °I. , 989`ecan8" " '; nliurmenf` `` e122201 X <br />03/22/2012 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y I N INA <br />15 1 <br />All facility employees have received the required on -the job training within the past Xear. <br />X <br />16 All faciliX em to ees hired within the past 30 Lays have received the re uir on -the job training. _ 1 <br />` X <br />Note: Any answer of "N" should be explained in the comment section on the foil wing page, and will req uixe <br />follow-up action. <br />Page 1 of 2 Nov,,ember 2004 <br />e n <br />