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r <br />D- -1 •- . ,• • Storage Operatorn6ly Visual h-k-weet4a, QfecV1i-,t <br />Facility Mame: <br />SAN JOAQUIN GENERAL HOSPITAL <br />Date: <br />Facility Address: <br />500 WEST HOSPITAL ROAD <br />3 <br />City: <br />FRENCH CAMP <br />Zip Code: CA 95231 <br />Designated UST Operator <br />Conducting the Inspection: JESSE BERUMEN <br />International.Co"�te Council Certification 8014628 -UC <br />Expiration Date: 05/24/2018 <br />Si tore: ®` <br />5a <br />Phone: ( 209 ) 367-4800 <br />Item <br />1 <br />Y = Yes N = No NA = Not A licabi <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />11 <br />Monitoring system is powered on and in proper operating mode. X <br />2 <br />Monitorin system is not currently showing any alarms or warnin s. <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 of the alarm history report/lorepoqft 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 />Note: Sumps where an alarm has occurred in the past month 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 />if smp inspection is re aired, 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 sums is only required in sums 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: T INE SUMP X <br />Sum Location: <br />Sum Location: PIPING SUMP X <br />Sum Location: <br />Sum Location: Sum Location: <br />7 <br />S ill containment structures are free of water, debris, and hazardous substance. <br />Y N NA I <br />Y—f N NA <br />Tank 1 - Contents: FILL BUCKET X Tank 3 - Contents: <br />X <br />Tank 2 - Contents: X Tank 4 -Contents:I <br />X <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are locatedprop erl . <br />Y I N NA <br />Y N NA <br />Dis enser 1 / 2 X Dispenser 9110 <br />X <br />Dis enser 3 / 4 X Dispenser 11 / 12 <br />X <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />X <br />Dis enser 7 / 8 X Dispenser 15 / 16 X <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 <br />Monitoring system certification has been completed within past 12 months. X <br />08/25/2016 <br />10 <br />Secondary containment tests have been completed within the r uired timeframe. X <br />03/24/2015 <br />11 <br />Spill containment structure(bucket) testing was completed within the past year. X <br />08/25/2016 <br />12 <br />Tank tightness _testing was completed within required timeframe. X <br />--- __�- <br />13 <br />Line ti tress testing was completed within required timeframe. SEE COMMENTS X <br />08/27/2015 <br />14 <br />Other Leguired testis maintenance was co leted within reuired timeframe. <br />Test: 4/2018 X <br />Test/Maintenance: <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />15 All facility employees have received the re uired on-the-job training within the past <br />16 All facili em to ees hired within the ast 30 da have received the re uired on -ti <br />Note: Any answer of "N" should be explained in the comment section on the following <br />follow-up action. <br />Page 1 of 2 <br />