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Designated ndergrom <br />� 1�Ionthly Viso; <br />Faci!t Name: <br />Facility Address: <br />SAN JOAQUIN GENERAL HOSPITAL <br />500 WEST HOSPITAL ROAD <br />I Date: 7719713 <br />City: <br />FRENCH CAMPZi <br />Code: CA 95231 <br />Designated UST Operator <br />Conducting the Inspection: JESSE BERUMEN <br />Intemationa de Council Certification 8014628 -UC <br />Ex iration Date: 06/06/2016 <br />Si afore: <br />Sump Location: PIPING SUMP X <br />Phone: 209 367-4800 <br />r*® Y = Yes, N = No, NA = Not A plicab <br />Item MONITORING PANEL / ALARM HISTORY Y N NA <br />E 111M Em om <br />I Monitoring system is powered on and in proper o eratin mode. X <br />2 Monitoring system is not currently showing any alarms or warnings. X <br />3 Alarm history report/log fpr the previous month is available, and has been reviewed by the X <br />Designated UST Operator. Attach a copy o the alarm history report/loreponft to thisform i 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 quaked service technician responded to, and <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this report. <br />1 i ction isre fired record results in item 6, below. <br />_7 ffiffilmmmmomm <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. w r <br />Note: Visual inspection of sumps is onLv refired in sumps where an alarm has occurred in the pag month or which there is no service record. <br />Y I <br />N Y N <br />Sump Location: TURBINE SUMP XSump <br />Location: <br />Sump Location: PIPING SUMP X <br />Sum Location: <br />Sum Location: <br />Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I <br />N NA Y N <br />NA <br />Tank 1— Contents: FILL BUCKET X <br />Tank 3 — Contents: <br />X <br />Tank 2 — Contents: <br />X Tank 4 — Contents: <br />X <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located properl . <br />Y <br />N NA Y I N <br />NA <br />Dispenser 1/ 2 <br />X Dispenser 9110 <br />X <br />Dispenser 3 / 4 <br />X Dispenser 11 / 12 <br />X <br />Dis enser S / 6 <br />X Dispenser 13 / 14 <br />X <br />Dis eraser 718 <br />X Dispenser 15 16 <br />X <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require <br />follow-up action. t `j <br />Page 1 of 2 November 2004 <br />