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ST) eratol <br />derground Storage Tank ku Al <br />Designated ection Checklis <br />Monthly Visual Insp <br />Ill 11, <br />SAN JOAQUIN <br />GENERAL HOSPITAL Date: ' <br />Facili Name: 500 WEST HOSPITAL ROAD Zi Code: CA 45231 <br />Facili Address: SSE BERUMEN <br />Ci FRENCH.CANIP <br />erator Conduc ' the Ins ection: JE Ex iration Date: 06/06/21 <br />Desi ated UST phone: 209 ) 367-4800 <br />international Council ertification 8014628 -UC Y <br />Si afore: ORING PANEL / ALARM HISTORY <br />IVIONIT <br />Item ro er o eratin or mode. <br />1 <br />Monitor s Le -115 owered on and alarms or warnings. <br />2 view ell.1 <br />Monitorin s stem is not currentl showin an <br />for the previous month is available, anile o ton to this ormyi e <br />3 Alarm history report/1og o the alarm hist <br />Desi ated UST eratol'. Attach a co <br />for the revious month has been res avenot alarmed m the ast month. <br />4 Each alarm to containment sum s h <br />5 Sensors located in tanto- Past month: <br />5a List all tank -top sumps where alarms occurred in the <br />Past month ropriate service to this <br />9ualrfied servic <br />n the <br />must be inspected unless a <br />Note: Sumps where an alarm haste al rm.tAttac docume <br />taction ging appr <br />properly addressed t� cause °f <br />1 in ection is re fired, record results in item 6, below• <br />UST SYSTEM INSPE douosubstance. Sens <br />debris, and ha occurred in the ast mon <br />6 Tto containment sumps are free of water, s where an alarm <br />ank- P s is on re uired in su <br />Note: Visual ins coon o sum Y N <br />X Sum Location: <br />INE SUMP X Sum Location: <br />Sum Location: 'r Location: <br />Iri Sum Location: PIPINGS Sum loos substance. <br />Sum Location: debris, and Nazar <br />Sill containment stri'ctur'es are free of waYr, N NA <br />7 Tank 3 — Contents: <br />L BUCKET X X Tank 4 — Contents: <br />Tank 1—Contents: FIL d hrdous substan <br />Tank 2 — Contents: debris, an <br />Under-dis enser containment areas are freYof wNater'NA <br />8 X Dis enser 9110 <br />Dis enser I / 2 X Dispenser 11 / 12 <br />Dis enser 3 / 4 X Dis enser 13 / 14 <br />Dis enser 5 / 6 X Dis enser 15 /.16 <br />Dis enser 7 / 8 INSPECTION <br />PAPERWORK <br />stem cert2 months - <br />ted w in <br />ification has bee nom feted w thin the re lu d gime ' zt <br />9 M, toren s X <br />10 Secon containment tests have been <br />ill containment structure ucket testm was com leted within the ast ear' <br />11 S e SEE COMMENTS X <br />timeframe. <br />12 Tank ti tress testin waass com leted w thin re uired innefram fired timeframe, <br />13 Line ti fitness testin tenance was com feted within r ; - /2018 X <br />14 Other re uired testm <br />Test. <br />Te st/Maintenance: <br />Test/Maintenance: EMPLOYEE TRAINING <br />FACILITY EMI' within the past yea <br />d there uired on -the= ob trainin TTude c <br />X = - <br />03/24/2015 <br />15 All facili em to ees have receive s have received the re , e, and will require <br />All facili em to ees hired within the ast 30 da <br />16 ®f �N" should be explained in the comment section on the following Pall. <br />Note: Any answer r, <br />folio -up action. <br />r 2004 <br />Page l of 2 i" <br />