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Designat Underground Storage Tank (US erat <br />Monthly Visual Inspection Checklist <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: <br />Facility Address: 500 WEST HOSPITAL ROAD <br />City FRENCH CAMP Zip Code: CA 95231 <br />Designated USTQperator Conducting the Inspection: JESSE BERUMEN <br />International odk Council C ification 8014628 -UC Expiration Date: 06/06 <br />Signal Phone: ( 209 367-4800 <br />Y= <br />Item MONITORING PANEL / ALARM HISTORY <br />1 Monitonng system is powered on and in pro er o eratin mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operat6r. Attach a copy of the alarm history report/logreportllog to thisform i av <br />4 Each alarm for the previous month has been res onded to a ro riatel . <br />5 Sensors located in tank -top containment sumps have not alarmed in the past month. <br />5a _ 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 resl <br />properly addressed, the cause of the alarm. Attach documentation verging appropriate service to this report. <br />1 su ins ection is required, record results in item 6, below. <br />am UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located <br />Note: Visual inspection o sums is only required in EMs where an alarm has occurred in the past month or which there <br />Y I N EM <br />Sump Location: TURBINE SUMP X <br />Sump Location: PIPING SUMP X <br />Sump Location: <br />7 Spill containment structures are free of water, del <br />Y N <br />Sump Location: <br />Sump Location:_ <br />Sum Location: <br />and hazardous substance. <br />NA <br />Tank 1— Contents: FILL BUCKET X <br />Tank 2 — Contents: X <br />8 Under -dispenser containment areas are free of water, det <br />Y N INA <br />Dispenser 1/ 2 X <br />Dis enser 3 / 4 X <br />Dispenser S / 6 X <br />Dispenser 7 / 8 X <br />Tank 3 — Contents: <br />Tank 4 — Contents: <br />and hazardous substance. Sensors are <br />9/10 <br />11112 <br />13114 <br />15116 <br />Page 1 of 2 - November"2004 <br />PAPERWORK INSPECTION <br />YIN INA <br />DATE <br />9 <br />Monitoring system certification has been completed within past 12 months. <br />X <br />08/22/ <br />10 <br />Secondarycontainment tests have been completed within the required timeframe. <br />X <br />03/24/2 <br />H <br />Spill containment structure(bucket) testing was completed within the past yean <br />X <br />08/22/2 <br />12 <br />Tank tightnegs testing was completed within required timeframe. <br />X <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS <br />X <br />08/22/20 <br />14 <br />Other required testis maintenance was completed within required timeframe. <br />t <br />Test: Tr'11annual;SB989j'$ei6uda Cont$inmenttestin,' 4n0344/2018 <br />X <br />03/24/201 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N N <br />15 <br />All facility employees have received the required on-the-job training within the past year. <br />X <br />16 <br />All facili em to ees hired within the past 30 da s have received the re uire =on=th6= <br />6b training. <br />X <br />IL <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Page 1 of 2 - November"2004 <br />