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Designate nderground Storage Tank (UST erator <br />Monthly Visual Inspection Checklist , <br />SAN JOAQUIN GENERAL HOSPITAL Date: <br />Facili Name: <br />Facili Address: 500 WEST HOSPITAL ROAD Zi Code: CA 95231 <br />Ci FRENCH CAMP <br />Desi ated UST Operator Conductin the Ins ection: JESSE ----TBERUNiration Date: 06/06/2016 <br />Internationa o e Council fication 8014628 -UC phone: ( 209 ) 367-4800 <br />Si ature- Y = Yes, N <br />MONITORING PANEL /ALARM HISTORY <br />Item a <br />1 Monitoringsystem is powered on and in ISM <br />roper operating mode. <br />2 Monitoring system is not currently Showing any alarms or warnin s. <br />has beenreviewed by <br />3 Alarm history report/log for the previous moonth is the alarm htstoanre ordloto this orm i�availa <br />Desi ated UST eratdr. Atta <br />month has been responded to a ro riatel . <br />4 Each alarm for the revious <br />sum shave not alarmed in the ast month. <br />5 Sensors located in tank -to containment <br />— <br />Sa - List all tank -top sumps where alarms occurred in the past month:tec <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service to this report. <br />Attach documentation verging appropriate service <br />properly addressed the cause of the alarm. <br />fired, record results in item 6, below. <br />1 s i ectian is re <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors <br />an alarm has occurred in the ast month or <br />Note: Visual inspection o sums is onLy re uired Ysum Nwhere <br />Sum Location: INE SUMP X <br />Sum Location: <br />Sum Location: PIPING SUMP X <br />Sum Location: <br />Sum Location: <br />Sum Location: <br />S ill structures are free of water, deNbris,Nand hazardous substance. <br />7 containment <br />w <br />Tank 1– Contents: FILL BUCKET X Tank 3 –Contents: <br />X Tank 4 – Contents: <br />Tank 2 – Contents: <br />areas are free of water, debris, and hazardous substance.-, <br />8 Under -dispenser containment <br />Y N NA <br />X Dis enser 9 /10 <br />Dis enser 1 / 2 <br />4 X Dis enser 11 <br />Dis enser 3 / 4 <br />X Dis enser 13 <br />R <br />Dis enser 5 / 6 <br />X Dis enser 1 S / 16 , � <br />Dis enser 7 / 8 <br />dA DATE DONE <br />PAPERWORK INSPECTION <br />X <br />08/17/2015 <br />9 Monitoringsystem certification has been completed. within act 12 months. d timeframe. X <br />uire <br />03/24/2015 <br />10 secondarycontainment tests have been com leted wn the re <br />leted within the ast ear. X <br />08/17/2015 <br />11 S ill containment structure (bucket)testingwas com <br />Tank tightness testing was com leted within re uired timeframe. <br />X --- <br />_ __12 <br />08/22/2014 <br />12X <br />13 Line ti htness testingwas com leted within re uired timeframe. SEE COMMENTS <br />14 Other re uired testin maintenance was completed within required timeframe. <br />X <br />03/24/2015 <br />Test: Cr»ieual S1s989a SeQonda s ntaieeetittestin )uE Q3124/2018 <br />Test/Maintenance: <br />Test/Maintenanee: 4� <br />Y N NA <br />FACILITY EMPLOYEE TRAINING <br />15 All facili em to ees have received the re uired on -the= ob training within the past year. X <br />30 da s have received the re ` fired on -the -'tib trainin . X <br />16 All facili em to ees hired within the ast <br />section on the olio to a e, and wilt require <br />$ P g <br />Note: Any answer of "N" should be explained in the comment <br />follow-up fiction. . -. <br />1 <br />" Nnv em4r 2004 <br />Page 1 of 2 <br />