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C <br />Name: <br />Address: <br />UST <br />Designate nderground Storage Tank (USTOperator <br />Monthly Visual Inspection Checklist <br />SAN JOAQUIN GENERAL HOSPITAL <br />500 WEST HOSPITAL ROAD <br />FRENCH CAMP Zip Code: CA 95231 <br />ator Conducting the Inspection: JESSE BERUMEN <br />until Certification 8014628 -UC Ex iration Date: 06/06/2016 <br />Phone:(209 367-4800 <br />Y=Yes,N=No,NA= <br />Item <br />MONTTORIN <br />1 <br />Monitoring system is powered on and in ro er operating mode. X <br />2 <br />M—onitoring system is not currently showing any alarms or warnings. X <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the X <br />Designated UST Operator. Attach a copy o the alarm history report/logreport1log to this orm if available. <br />4 <br />Each alarm for the previous month has been responded to a ro riatel . X <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. X <br />Sa <br />--List all tank -top sumps where alarms occurred in the past month: u r <br />Note: Sumps where an alarm has occurred in the past month must be inspected unless a qualified service technician responded to, and <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this report. <br />1 su ins coon is lauired, record results in item 6, below. <br />60111111 <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: Visual inspection o s is one re ired in su s where an alarm has occurred in the t month or which there is no service record <br />Y N Y N <br />Sum Location: TURBINE SUMP X Sum Location: <br />Sum Location: PIPINGS X Sum Location: <br />Sum Location: Sum Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y N NA Y N NA <br />Tank 1 – Contents: FILL BUCKET X Tank 3 – Contents: X <br />X <br />Tank 2 – Contents: X Tank 4 – Contents: <br />Under -dispenser containment areas are free of water, debris, and hazardous substapce. Sensors are located )roper I <br />8 <br />Y N NA NA <br />Dispenser 1/ 2 X Dispenser 9110 X <br />Dispenser 3 / 4 X Dispenser 11 / 12 X <br />Dispenser 5 / 6 X Dispenser 13 / 14X <br />Dis enser 7 / 8 X Dispenser 15 / 16 X <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 <br />Monitoring s stem certification has been completed within past 12 months. X 08/22/2014 <br />10 <br />_'Se_condary containment tests have been cam leted within the required timeframe. X 03/24/2015 <br />11 <br />Spill containment structure(bucket).testing was completed within the past year.. X 08/22/2014 <br />12 <br />Tank tightness testin was com leted within re uired timeframe. X �-'- <br />13 <br />Line tightness testingwas completed within required timeframe. SEE COMMENTS X 08/22/2014 <br />14 <br />Other re uired testin maintenance was com feted within required timeframe. <br />eek:: Ki ht <br />Test � , _ X03724/2018 X 03/24/201 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />15 <br />All facility an to ees have received the required on-the-'ob trainin g within the,,past ear. -. X <br />16 <br />All facilityem to ees hired within the past 30 da s have received the re uired`on-the-'ob trainin , <br />."A will rPnreir.P <br />Note: Any answer or --1V" snouiu De Capeauicu ue Leet <br />follow-up action. <br />Page 1 of 2 NovFmber 2004 <br />_, .. <br />