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DesignateUnderground Storage Tank (u,"10 <br />Monthly Visual Inspection Checklist <br />Facility <br />Name: SAN JOAQUIN GENERAL HOSPITAL <br />Date: <br />Facility <br />Address: 500 WEST HOSPITAL ROAD <br />Y N <br />City: <br />FRENCH CAMP <br />Zi Code: CA 95231 <br />Designated <br />UST Operator Conducting the Inspection: JESSE BERUMEN <br />Internatio#9de Council Certification 8014628 -UC <br />Ex iration Date: 05/24/2018 <br />Si na <br />Phone:( 209 ) 367-4800 <br />Y=Yes.N=NO.NA= <br />FACILITY EMPLOYEE TRAINING Y I N I NA <br />15 All fac lity employees have received the required on-the-job training within the past year, X <br />16 All facili em to ees hired within the past 30 da s have received the re uired e ' .b <br />Note: Any answer of "N" should be explained in the comment section on the follo' ' g page, and will require J,n <br />follow-up action. <br />Page 1 of 2 E.: Navmbe(4 <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 />ism ins ection is re aired, record results in item 6, below. <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 of sums is only required in sums where an alarm has occurred in the past month for which there is no service record. <br />Y N <br />Y N <br />Sum Location: TURBINE SUMP X <br />Sump Location: <br />Sump Location: PIPING SUMP X <br />11 <br />Sump Location: <br />Sump Location: <br />Sump 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 located 3roperly. <br />Y N NA <br />Y N NA <br />Dispenser I / 2 X Dispenser 9 / 10 <br />X <br />Dispenser 3 / 4 X Dispenser 11 / 12 <br />X <br />Dispenser S / 6 X Dispenser 13 / 14 <br />X <br />Dispenser 7/ 8 X Dis enser 15 16 <br />X <br />PAPERWORK INSPECTION Y N <br />NA DATE DONE <br />Monitoring system certification has been completed within past 12 months. X <br />08/25/2016 <br />Secondary containment tests have been completed within the required timeframe. X <br />03/24/2015 <br />ontainment structure ucket testin was completed within the past year. X <br />08/25/2016 <br />tightness testingwas com leted within re uired timeframe. <br />X <br />tress testin was com feted within required timeframe. SEE COMMENTS X <br />08/27/2015 <br />14 <br />Other Leauired testin maintenance was completed within re uired timeframe. <br />Test: °4/2018 X <br />Test/Maintenance: <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y I N I NA <br />15 All fac lity employees have received the required on-the-job training within the past year, X <br />16 All facili em to ees hired within the past 30 da s have received the re uired e ' .b <br />Note: Any answer of "N" should be explained in the comment section on the follo' ' g page, and will require J,n <br />follow-up action. <br />Page 1 of 2 E.: Navmbe(4 <br />