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DesignatedInderground Stomge Tank (UST)%erat <br />Monthly r' • <br />Facility Name: <br />Facili Address: <br />SAN JOAQUIN GENERAL HOSPITAL <br />500 WEST HOSPITAL ROAD <br />Date: <br />City: <br />FRENCH CAMP <br />Zip Code: CA 95231 <br />Designated UST <br />Operator Conducting the Inspection: JESSE BERUMEN <br />International <br />a Council rtification 8014628-UC�Ex <br />iration Date: 06/06/2016 <br />Si afore: <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Phone: 209 367-4800 <br />Y= Yes, N=No <br />Item Z 7 MONITORING PANEL / ALARM HISTORY <br />NEERNME <br />1 Monitoring system is powered on and in ro er operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history report/logfor the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy of the alarm history report/logreportllog to thisform if available. <br />4 Each alarm for the previous month has been responded to appropriately. <br />5 Sensors located in tank -to containment sumps have not alarmed in the past month. <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 quaked service technician resp <br />properly addressed the cause of the alarm. Attach documentation ver6ing appropriate service to this report. <br />If sump inspection is required 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 <br />Note: Visual inspection os is on re ired in s where an alarm has occurred in the LgLt month for which there' <br />Y N <br />Sump Location: TURBINE SUMP X <br />Sump Location: <br />Sump Location: PIPING SUMP X <br />Sump Location: <br />Sump Location: <br />Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Tank 1— Contents: FILL BUCKET X I Tank 3 — Contents: <br />Tank 2 — Contents: X I Tank 4 —Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substan6e. Sensors are <br />Y N NA <br />< <br />Dispenser 1/ 2 X Dis enser 9110 <br />Dispenser 3 / 4 X Dispenser 11 / 12 <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />Dis enser 7 / 8 X Dis enser 15 / 16 <br />PAPERWORK INSPECTION <br />9 Monitoring system certification has been completed within past 12 months. <br />10 secondary containment tests have been completed within the re uired timeframe. <br />11 Spill containment structure ucket testing was completed within the past year. <br />12 Tank tightness testing was completed within required timeframe. <br />13 Line ti htness testing was completed within required timeframe. SEE COMMENTS <br />14 Other required testin maintenance was completed within required timeframe, <br />Test: 018 <br />Test/Maintenance: <br />Test/Maintenance: <br />I FACILITY EMPLOYEE TRAINING <br />1 15 1 All facilitv emDlovees have received the required on-the-iob training within the <br />1 16 1 All facility employees hired within the past 30 days have received the required <br />Note: Any answer of "N" should be explained in the comment section on the follol <br />follow-up action. <br />►1 <br />08/17t.,vY_ <br />9 <br />Page 1 of 2 F Novemtaer 2004 <br />