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Designat Underground Storage T US Operator Monthly Visual Inspection Checklist 2Desi ame: SAN JOAQUIN GENE HOSPITAL Date: ddress: 500 WEST HOSPITAL ROAD FRENCH CAMP Zi Code: CA 95231 d UST erator CodtihIns ection:JESSE BERUMEN ode Council Certification 8014628 -UC Ex iration Date: 05/24/2018 : Phone: ( 209 ) 367-4800 Y =Yes N = No NA =Not licab Item MONITORING PANEL / AL HISTORY YSEE= N NA 1 MonitorWi in s stem is owered on and in ro proper o eratin mode. X 2 Monitoring system is not currently showing any alarms or warnings. X 3 Alarm history report/log for the previous month is available, and has been reviewed by the X Designated UST Operator. Attach a copy o the alarm history repoLqog to this orm i available) 4 Each alarm for the previous month has been responded to a ro riatel X 5 Sensors located in tank -to containment Limps have not alarmed in the past month. X 5a - List all tank -top sumps where alarms occurred in the past month: Note: Sumps where an alarm has occurred in the past month must be inspected unless a quaked service technician responded to, and properly addressed, the cause of the alarm. Attach documentation verifying appropriate service to this report. I sumpinsvection is re wired, record results in item 6, below. UST SYSTEM INSPECTION 6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. Note: Visual ins ction of sums is onl required in sums where an alarm has occurred in the past month or which there is no service record. Y N Y N Sum Location: T INE SUMP X Sum Location: !Sump Location: PIPING SUMP X Sum Location: Sump Location: Sum Location: 7 Spill containment structures are free of water, debris, and hazardous substance. Y. IN NA PAPERWORK MSecondan, s stem certification has been complete containment tests have been com leted ainment structure ucket testness testis was com leted within re uv 13 1 Line tightness testing was completed within re uir 14 Other required testis maintenance was completed Test: !1 _.: °�.... Test/Maintenance: Tank 3 — Contents: Tank 4 — Contents: and hazardous substance. Sensors are located 9/10 11112 13114 15116 d within past 12 months. within the required timeframe. mpleted within the past year. ed timeframe. A timeframe. SEE COMMENTS within�required timeframe. "ilial~kl X4/2018 W EM WM M&M Me 94 FACILITY EMPLOYEE TRAINING 15 All acility employees have received the required on-the-job tmiiiirig within the past year. 16 All facili em to ees hired within the pasL2Ldays, have received the re uired on thR`6b train Note: Any answer of "N" should be explained in the comment section on the following iage" and w follow-up action. wi dU mikV1 Page 1 of 2 Noyembgr3 004 Tank 1 — Contents: FILL BUCKET X Tank 2 — Contents: I X 8 Under-dis eraser containment areas are free of water, det Y N NA Dis enser 1 / 2 X Dis enser 3 / 4 X Dis enser 5 / 6 X Dis enser 7 / 8 X PAPERWORK MSecondan, s stem certification has been complete containment tests have been com leted ainment structure ucket testness testis was com leted within re uv 13 1 Line tightness testing was completed within re uir 14 Other required testis maintenance was completed Test: !1 _.: °�.... Test/Maintenance: Tank 3 — Contents: Tank 4 — Contents: and hazardous substance. Sensors are located 9/10 11112 13114 15116 d within past 12 months. within the required timeframe. mpleted within the past year. ed timeframe. A timeframe. SEE COMMENTS within�required timeframe. "ilial~kl X4/2018 W EM WM M&M Me 94 FACILITY EMPLOYEE TRAINING 15 All acility employees have received the required on-the-job tmiiiirig within the past year. 16 All facili em to ees hired within the pasL2Ldays, have received the re uired on thR`6b train Note: Any answer of "N" should be explained in the comment section on the following iage" and w follow-up action. wi dU mikV1 Page 1 of 2 Noyembgr3 004