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DesignaWndergroundStorage(AWP <br />Monthlv Visual -! •_ •I I" <br />Facili Name: SAN JOAQUIN GENERAL HOSPITAL <br />Facility Address: 500 WEST HOSPITAL ROAD <br />Date: <br />City: FRENCH CAMP <br />Zi Code: CA 952 <br />Designated USI Operator Conducting the Inspection: JESSE BERUMEN <br />Internatioo e Counc' Certification 8014628 -UC <br />Ex iration ; <br />Si afar <br />Phone: ( 209 36 <br />Item MONITORING PANEL / ALARM HISTORY <br />1 Monitoring system is powered on and in proper opmatigg operatingmode. <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 reviewer <br />Designated UST OpLrator. Attach a cqpy o the alarm histog report/loreponft to this o <br />4 Each alarm for the previous month has been responded to appropriately. <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 />FACILITY EMPLOYEE TRAINING Y N NA <br />15 All facility employees have received the required on-the-job training within the past year. X <br />16 All facili em to ees hired within theast 30 da s have received the re on-the-'ob training. X <br />Note: Any answer of "N" should be explained in the comment section on the Mowing page, and will require. <br />follow-up action. <br />Page 1 of 2 ° a . Novernl ei 2004 <br />Note: Sumps where an alarm has occurred in the past. month must be inspected unless a quaked <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service ti <br />I su t ction is re wired, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />Tank -top containment sumps are free of water, debris, and hazardous substance. c' <br />_ <br />6 <br />Note: Visual ins ctton ofsunips is only Mui in sumps where an alarm has occurred in the pas4 <br />Y N <br />Sum Location: INE SUMP X Sum Location: <br />Sum Location: PIPING SUMP X Sum Location: <br />Sum Location: Sump Location: <br />Spill containment structures are free of water, debris, and hazardous substance. <br />7 <br />Y I N FNAT <br />Tank 1 — Contents.- FILL BUCKET X Tank 3 —Contents: <br />3. <br />Tank 2 — Contents: X Tank 4 — Contents: <br />Under -dispenser containment areas are free of water, debris, and hazardous subsi <br />--, <br />8 <br />Y I N I NA <br />a <br />Dispenser 1/ 2 X Dispenser 9 /10 <br />Dispenser 3 / 4 X Dis eraser 11 / 12 <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />Dis eraser 7 / 8 X Dis eraser I S / 16 <br />PAPERWORK INSPECTION <br />Monitoring system certification has been completed within past 12 months. <br />Secondary containment tests have been completed within the required timeframe. <br />Wiz: <br />X 03/22/2u ` <br />9 <br />10 <br />11 <br />Spill containment structure(bucket) testing was completed within the past year. <br />X 08/16/2013 <br />12 <br />Tank tightness testing was completed within re aired timeframe. <br />X ---------- <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS <br />X 08/16/2013 <br />14 <br />Other reaired testing/ maintenance was completed within required timeframe. <br />Test: "'` "u `" a8ri i" 3%0 <br />X 03/22/2012 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />15 All facility employees have received the required on-the-job training within the past year. X <br />16 All facili em to ees hired within theast 30 da s have received the re on-the-'ob training. X <br />Note: Any answer of "N" should be explained in the comment section on the Mowing page, and will require. <br />follow-up action. <br />Page 1 of 2 ° a . Novernl ei 2004 <br />