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� < , t1 <br />` i�7 `` \`�� `\ �Y 1 <br />` J <br />Desi nate radar round Storage Tank US `h <br />g g g ( perator <br />Monthly Visual Inspection Checklist <br />SAN JOAQU GENE HOSPITAL Date: ,�" <br />500 WEST HOSPITAL ROAD <br />Facility Name: <br />Item <br />Y = Yes N = No NA = Not Applicable <br />MONITORING PANEL / AL HISTORY Y N NA <br />FacilityAddress: <br />1 <br />Monitorin s stem is powered on and in proper operating mode. <br />City: <br />FRENCH CAMP <br />Zi Code: CA 95231 <br />Designated US <br />Operator Conductingthe Inspection: JESSE BERUMEN <br />Internatio C <br />e Council rtification 8014628 -UC <br />Expiration Date: 05/24/2018 <br />Si na <br />Phone: ( 209 ) 367-4800 <br />Page 1 of 2 Noyember 2004 <br />Item <br />Y = Yes N = No NA = Not Applicable <br />MONITORING PANEL / AL HISTORY Y N NA <br />1 <br />Monitorin s stem is powered on and in proper operating mode. <br />X <br />2 <br />Monitoringsystem is not currentlyshowingany 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 co o the alarm histo re ort/lo to this form i 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 -to 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 />EUST <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br />properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />If sum inspection is required, record results in item 6, below. <br />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 onlyre uired 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: TURBINE SUMP X <br />Sum Location: <br />Sum Location: PIPING SUMP X <br />Sum Location: <br />Sum Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Y N NA <br />Tank 1 — Contents: FILL BUCKET X Tank 3 — Contents: <br />X <br />Tank 2 — Contents: X Tank 4 — Contents: <br />X <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are locatedproperly. <br />Y N NA <br />Y N NA <br />Dispenser 1 / 2 X Dis eraser 9 / 10 <br />X <br />Dispenser 3 / 4 X Dis enser 11 / 12 <br />X <br />Dis enser 5 / 6 X Dis enser 13 / 14 <br />X <br />Dis enser 7 / 8 X Dis enser 15 / 16 <br />PAPERWORK INSPECTION Y N NA <br />X <br />DATE DONE <br />9 <br />Monitoringsystem certification has been completed within past 12 months. X <br />08/25/2016 <br />10 <br />Secondarycontainment tests have been completed within the required timeframe. X <br />03/24/2015 <br />11 <br />Spill containment structure (bucket)testingwas completed within the past year. X <br />08/25/2016 <br />12 <br />Tank tightness testingwas completed within required timeframe. X <br />--------- ____ <br />13 <br />Line tightness testingwas com leted within required timeframe. SEE COMMENTS X <br />08/27/2015 <br />14 <br />Other required testing/maintenance was cam leted within re uired timeframe. <br />Test: b�°� /2018 X <br />Test/Maintenance: <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facilityemployees have received the required on-the-job trainin within the t•year,., <br />X <br />16 <br />All facili! em to ees hired within the past 30 days have received the re uired-the-'ob t� 1a iin . <br />r <br />Note: Any answer of G`N" should be explained in the comment section on the folio n age,, in�� ill reywie A <br />follow-up action. <br />t h, <br />)aP <br />Page 1 of 2 Noyember 2004 <br />