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1 <br />RM-Witnderground Storage Tank (US <br />Name: SAN JOAQUIN GENERAL HOSPITAL <br />Address: 500 WEST HOSPITAL ROAD <br />FRENCH CAMP <br />ted UST Operator Conducting the Inspection.—It <br />Tonal Code Council Certification 8014628 -UC - <br />an Checklist <br />Date: _L — <br />X1 c <br />Expiration Date: 05/24/2018 <br />Phone: ( 209 ) 367-4800 <br />Y = Yes N = No NA = Not <br />Item <br />1 <br />MONITORING PANEL / ALARM HISTORY <br />Monitoring system is powered on and mi proper operatigg operatingmode. <br />Y N NA <br />X <br />2 <br />Monitan n system is not currend showing my 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 />Desi ted UST erator. Attach a copy of the alarm history report/lorqpoLqo& to this form 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 qualified service technician responded to, and <br />properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. <br />Ifs =lion is re uired, record results in item 6, below. <br />IMMEMEEMEM <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 o sums is only required in sums where an alarm has occurred in thepast month or which there is no service record. <br />Y N <br />Y N <br />Sum Location: TURBINE SUMP X Sum Location: <br />Sum Location: PIPING SUMP X Sum Location: <br />Sum Location: Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N INA IY <br />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 located 3roperly. <br />Y N NA <br />Y N NA <br />Dispenser I / 2 X Dispenser 9 / 10 <br />X <br />Dis eraser 3 / 4 X Dis enser 11 / 12 <br />X <br />Dispenser S / 6 X Dis enser 13 / 14 <br />X <br />Dispenser 7 / 8 X Dis enser 15 / 16 <br />PAPERWORK INSPECTION Y N NA <br />X <br />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 compfeted within the required timeframe. X <br />03/24/2015 <br />11 <br />Spill containment structure ucket testing was completed within the past year. X <br />08/25/2016 <br />12 <br />Tank tightness testin was completed within required timeframe. X <br />----- __M__ <br />13 <br />Line tightness testinwas completed within re uired timeframe. SEE COMMENTS X <br />08/27/2015 <br />14 <br />Other Lequired tech maintenance was completed within reuired timefiame. <br />Test: , . 4/2018 X <br />1 : <br />Test/Maintenance: <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facility employees have received the required on -the job training within the,"'year" <br />16 <br />Note: <br />All facili em to ees hired within the past 30 da s have received the re uired o `-the- trainin . <br />Anv answer of 6IN" should be explained in the comment section on the follow ' g Vage, and will require <br />follow-up action. <br />Page 1 of 2 <br />n <br />LUr <br />' Noup00er 2004 <br />