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Designate Underground Storage Tank (UST) Operator' <br />Monthly Visual Inspection Chec ist ! ti <br />Facility Name: <br />SAN JOAQUIN GENERAL HOSPITAL <br />I Date: q13 Ile" <br />Facility Address: <br />500 WEST HOSPITAL ROAD <br />i <br />City: <br />FRENCH CAMP <br />Zi Code: CA 95231 <br />Designated UST <br />erator Conducting the Inspection: JESSE BERUMEN <br />International o <br />Councilification 8014628 -UC <br />Expiration Date: 06/06/ - <br />Si ature: <br />Phone: ( 209 ) 367-4800 <br />r® <br />Item MONITORING PANEL / ALARM HISTORY <br />1 Monitoring system is powered on and'in groper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings- <br />3 <br />arnin s.3 Alarm history report/log for the previous month is available, and has been reviewed by <br />Designated UST Operator. Attach a copy of the alarm history report/logreport1log to this orm i <br />4 Each alarm for the previous month has been responded to appro riatel . <br />5 Sensors located in tank -top containment sums have not alarmed in the past month. <br />5a - List all tank --top sumps where alarms occurred in the past month:Mo,+jAna <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a quadded servic <br />properly addressei4 the cause of the alarm. Attach documentation verging appropriate service to this r <br />!Zsu= inspection is re record results in item 6, below. <br />MEHIMME MM <br />UST SYSTEM INSPECTIONr <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sens <br />Note: Visual inspection of sumps is only required in sumps where an alarm has occurred in the Dalt in t�R <br />Y N EM <br />Sump Location:. TURBINE SUMP X ump Location: <br />Sump Location: PIPING SUMP X Sump Location: <br />Sump Location: Sump Location: <br />7 Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA <br />Tank 1 - Contents: FILL BUCKET XTank 3 —Contents: <br />Tank 2 — Contents: I X Tank 4 — Contents: <br />8 Under -dispenser containment areas are free of water, debris, and hazardous sub <br />Y I N I NA <br />Dispenser 1/ 2 <br />Dispenser 3 /4 <br />Dispenser 5 / 6 <br />Dispenser 7 / 8 <br />MEMMENEM EWE <br />PAPERWOIi <br />9 Monitorin system certification has been com ` 1 <br />10 Secondary containment tests have been com let <br />H Spill containment structure ucket testing was <br />12 Tank tightness testing was completed within re <br />13 Line tightness testing was completed within re <br />14 Other required testis maintenance was com le` <br />Test: Noun" 989.'` ,* "i <br />Test/Maintenance: _ <br />Test/Maintenance: <br />X Dispenser 9 / 10 <br />X Dispenser 11 / 12 <br />X Dis enser 13 / 14 <br />X Dis enser 15 / 16 <br />INSPECTION <br />d within past 12 months. <br />within the required timeframe., <br />m leted within the past year. <br />ed timeframe. <br />;d timeframe. SEE COMMENT <br />within required timeframe. <br />.)' £.e. X4/2018 <br />L4/2015 <br />X '17/2015 <br />X a�_w <br />S X 08/22/2014 <br />FACILITY EMPLOYEE TRAINING Y I N NA <br />15 All facility employees have received the required on-the-`ob training within theash. X <br />16 All facili em to ees hired within the past 30 !lays have received the required on- ' ejob trainin M <br />Note: Any answer of "N" should be explained in the comment section on the following' page, and wilt require <br />follow-up action. <br />." ..-�„ <br />Page 1 of 2 Novembe 2004 <br />