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Facility Name: <br />SAN JOAQUIN GENERAL HOSPITAL <br />Date: <br />Facility Address: <br />500 WEST HOSPITAL ROAD <br />Spill containment structures are free of water, debris, and hazardous substance. <br />City: <br />FRENCH CAMP <br />Zip Code: CA 95231 <br />Designated UST <br />Operator Conducting the Inspection: JESSE BERUMEN <br />Internationa <br />a Council Certification 8014628 -UC <br />Expiration Date: 05/24/2018 <br />Si tore <br />X <br />Phone: ( 209 ) 367-4800 <br />I - I Eli. 11 = 170. 1®1% <br />Item MONITORING PANEL / ALARM HISTORY Y N INA <br />INIZE a= <br />1 Monitoring system is powered on and in ro r operating mode. X <br />2 Monitoring system is not currently showing any alarms or warnings. X <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the X <br />Designated UST Operator.' Attach a copy of the alarm history report/logrgportfiog to thisform i available.) <br />4 Each alarm for the previous month has been responded to appropriately. z <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month. X <br />5a - List all tank -top sumps where alarms occurred in the past month: <br />6 <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 verifying appropriate service to this report. <br />isump inspection is required, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />k -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />,te: Visual inspection of sums is only required in sums where an alarm has occurred in the past month for which there is no service n <br />Y N Y N <br />Location: TURBINE SUMP X Sump Location: <br />Location: PIPING SUMP X Sump Location: <br />Page 1 of 2 1�fob60 <br />r <br />Sump Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N INA <br />Y N NA <br />Tank 1 -Contents: FELL 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 located ro erl . <br />Y N INA <br />Y N INA <br />Dispenser 1 / 2 X DY enser 9110 <br />X <br />Dispenser 3 / 4 X Dispenser 11 / 12 <br />X <br />Dispenser 5 / 6 X Dis enser 13114 <br />X <br />Dispenser 7 / 8 X Dis en ser 15 116 <br />IMEMESEEMEMINS <br />PAPERWORK INSPECTION Y N NA <br />X <br />in= <br />DATE DONE <br />9 <br />Monitoring system certification has been com leted within past 12 months. X <br />08/25/2016 <br />10 <br />Secondary containment tests have been completed within the required 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 re aired timeframe. g <br />--------- _-- <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS I X <br />08/27/2015 <br />14 <br />Other required testis maintenance was completed within required timeframe. <br />Test: ffigiffiM 014/2018 X <br />Test/Maintenance: <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y I N INA <br />15 <br />All facili em to ees have received the required on-the-job training within the past year. <br />X <br />16 All facility em to ees hued within the 2ast 30 da s have received the required o '" i6-'ob <br />Note: Any answer of "N" should be explained in the comment section on the followi j)�*'"and will require <br />follow-up action. W <br />Page 1 of 2 1�fob60 <br />r <br />