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Item MONITORING PANEL / ALARM HISTORY <br />EMEMEIEM- <br />1 Monitoring stem is powered on and in proper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. ' Attach a cTy of the alarm history report/7oreportl7og to thisform if avail <br />4 Each alarm for the revious month has been res onded to a ro datel . <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month. <br />Sa I _ 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 <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this re <br />If inspection is re fired, record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 <br />Designated erground Storage Tank (UST) rator <br />L015 <br />X 2015 <br />X <br />Monthly Visual Inspection Checklist <br />Facility Name: <br />SAN J®AQUIN GENERAL HOSPITAL Date: <br />Facility Address: <br />500 WEST HOSPITAL ROAD <br />City: <br />FRENCH CAMP Zip Code: CA 95231 <br />Designated UST Operator <br />Conducting the Inspection: JESSE BERUMEN <br />International de Counci Certification 8014628 -UC <br />Expiration Date: 06/06/2016 <br />r:,....,«.._o. _ Q <br />. ® _ _ _ . _ _ <br />Phone: ( 209 ) 367-4800 <br />Item MONITORING PANEL / ALARM HISTORY <br />EMEMEIEM- <br />1 Monitoring stem is powered on and in proper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. ' Attach a cTy of the alarm history report/7oreportl7og to thisform if avail <br />4 Each alarm for the revious month has been res onded to a ro datel . <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month. <br />Sa I _ 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 <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this re <br />If inspection is re fired, 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. ,ensors <br />Note: Visual ins ction o s is on re ired in sum s where an alarm has occurred in the t month o. <br />L015 <br />X 2015 <br />X <br />Y N <br />Sum Location: INE S X <br />Sum Location: <br />X 08/22/2014 <br />Sum Location: PIPINGS X <br />Sum Location: <br />Sum Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Test/Maintenance: <br />Y N I NA <br />Tank 1 -Contents: FILL BUCKET X Tank 3 — Contents: <br />Tank 2 — Contents: X Tank 4 —Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. <br />15 <br />Y N NA <br />year. X . <br />Dispenser 1/ 2 X Dispenser 9110 <br />All facili em to ees hired within the past 30 da s have received the required on � e= ob frai 'ft : 44 <br />Anv answer of "N" should be explained in the comment section on the followidg page, and will require <br />Dispenser 3 14 X Dispenser 11 / 12 <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />Dis enser 718 X I Dispenser 15 / 16 <br />YAr KWViceularr%_xrun <br />10 <br />11 <br />12 <br />1V1LVLLLLV11SA O.Y.- <br />Sec on containment tests have been com leted within the re wired timeframe. <br />Spill containment structure(bucket) testing was com leted within the past year. <br />Tank ti tress testingwas completed within required timeframe. <br />L015 <br />X 2015 <br />X <br />13 <br />Line tightness testiwas completed within required timeframe. SEE CO NTS <br />X 08/22/2014 <br />14 <br />Other required testing/maintenance was co m leted within required timeframe. <br />Test: ,� .�� /2018. <br />X 03/24/2015 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facili employees have received the required on the job training within the past <br />year. X . <br />16 <br />Note: <br />All facili em to ees hired within the past 30 da s have received the required on � e= ob frai 'ft : 44 <br />Anv answer of "N" should be explained in the comment section on the followidg page, and will require <br />follow-up action. <br />r <br />F <br />Page 1 of 2 Novern$02004 <br />