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DesignateWnderground Storage Tank (USA., <br />Monthly Visual Inspection Checklist <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: — <br />Facility Address: 500 WEST HOSPITAL ROAD <br />City: FRENCH CAMP Zip Code: CA 95231 <br />Designated UST Operator Conducting the Inspection: r q n d c ;1 a h I _e <br />International Code Council Certification 8014628 -UC Expiration Date: 05/24/2018 <br />Si nature Phone:( 209 ) 367-4800 <br />Y=Yes N=No NA= <br />Item MONITORING PANEL / ALARM HISTORY Y <br />111=11111m= ME <br />1 Monitoring system is powered on and in proper 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 reportl7og report/7oto thisform if available.) <br />4 Each alarm for the previous month has been responded to appropriately. X <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 />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 verging appropriate service to this report. <br />If sum ins ection is required, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual ins ction of sums is only required in sum s where an alarm has occurred in the past month for which there is no service record. <br />Y N 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 Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA Y N NA <br />Tank 1 – Contents: FILL BUCKET X Tank 3 – Contents: X <br />Tank 2 – Contents: X Tank 4 –Contents: X <br />8 Under-dis enser containment areas are free of water, debris, and hazardous substance. Sensors are located ro erl . <br />Y N NA Y N NA <br />Dis enser 1 / 2 X Dispenser 9110 X <br />Dispenser 3 / 4 X Dispenser 11 / 12 X <br />Dispenser S / 6 X Dispenser 13 / 14 X <br />Dispenser 7 / 8 X Dis enser 15 / 16 X <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 Monitoring system certification has been completed within past 12 months. X 08/25/2016 <br />10 Secondary containment tests have been completed within the required timeframe. X 03/24/2015 <br />11 Spill containment structure(bucket) testing was completed within the past year. X 08/25/2016 <br />12 Tank tightness testing was completed within required timeframe. XI ----- ----� <br />13 Line tightness testing was completed within required timeframe. SEE COMMENTS X 08/27/2015 <br />14 Other required testis maintenance was com leted within re uired timeframe. <br />Test � 4" �' itt �1� = t 4/2018X 03/24/2015 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />15 All facility em to ees have received the re uired on -the job training within the past year. I X <br />16 All facili em to ees hired within the past 30 days have received the required o job'-trainin . X <br />Note: Any answer of "N" should be explained in the comment section on the followO,'k page, and will require „ ya LLµ, <br />follow-up action. <br />Page 1 of 2 Nov crib r '2I) ° <br />