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C <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: <br />SAN JOAQUIN GENERAL HOSPITAL <br />Date: / <br />Facility Address: <br />500 WEST HOSPITAL ROAD <br />X <br />City: <br />FRENCH CAMP <br />Zip Code: CA 95231 <br />Designated UST <br />erator Conducting the Inspection: JESSE BERUN <br />International od <br />Council rtification 8014628 -UC <br />Expiration Date: 06/06/2016 <br />Signature: <br />5a <br />Phone:( 209 ) 367-4800 <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />X <br />3 <br />Alarm history report/log fqr the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy o the alarm history report/logreport1log to thisform if available. <br />X <br />4 <br />Each alarm for the previous month has been responded to approp6ately. <br />X <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. <br />X ` <br />5a <br />_ 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 qualified service technician responded to, <br />properly addressed the cause of the alarm. Attach documentation verng appropriate service to this report. <br />1 sump inspection is re wired, record results in item 6, below. <br />I <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 of sumps is onlyrequired in mwWs where an alarm has occurred in the past month or which there is ,, service <br />Y N <br />Y N <br />SuTe Location: TURBINE SUMIPX Sump Location: <br />Sump Location: PIPING SUMP X Sump Location: <br />Sump Location: Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N I NA <br />Y N <br />Tank 1– Contents: FILL BUCKET X Tank 3 –Contents: <br />Tank 2 – Contents: X Tank 4 – Contents: <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous substance. Sensors are located proper <br />Y I N NA <br />Y N <br />Dispenser 1/ 2 X Dispenser 9110 <br />Dispenser 3 /4 X Dispenser 11 / 12 <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />Dispenser 7 / 8 X Dispenser 15 / 16 <br />PAPERWORK INSPECTION Y N NA <br />DATE DO <br />9 <br />Monitoringsystem certification has been completed within past 12 months. X <br />08/22/2014 <br />10 <br />Secondarycontainment tests have been completed within the required timeframe. X <br />03/2015 <br />11 <br />Spill containment structure ucket testin was com feted within the past year. X <br />08/22/2014 <br />12 <br />Tank ti htness testingwas completed within required timeframe. X <br />—___ - <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS I X L 1 <br />08/22/2014 <br />14 <br />Other required testin maintenance was completed within required timeframe. <br />Test: ,i ". _ 9 eiii ,` n�tD��4/2018 X <br />Test/Maintenance: <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facility employees have received the re uired on-the-job training within the pastlyear. <br />X <br />16 <br />All facili em to ees hired within the past 30 days have received the re uired on -the= ob ti ainin . <br />X <br />note: Any answer oI -i-v' snouia De explalneu III LIIC wluulCUL AGGLR/u vu Lasc aveeoeeaaaf, Fa8"1 ....+ .•_....y-.••. <br />follow-up action. <br />Page 1 of 2 Nov r 2004 <br />