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Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checkjist,, <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: <br />Facility Address: 500 WEST HOSPITAL ROAD <br />City: FRENCH CAMP Zi Code: CA 95231 <br />Designated UST Qperator Conducting the Inspection: JESSE BERUMEN <br />International KdCouncil Cprtification 8014628 -UC Expiration Date: 06/06/2016 <br />Si ature: Phone:( 209 3674800 <br />Y = Yes. <br />Item I t/ MONITORING PANEL / ALARM HISTORY <br />1 Monitorin system is owered on and in proper operating 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 Operator. Attach a c9ey of the alarm histo report/log to this Orm if availa <br />4 Each alarm for the previous month has been responded to appropriately. <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 tech <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this report. <br />1 ins <br />on is = record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 . Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are <br />Note: Visual inspection o s is only re utred in sum s where an alarm has occurred in the past month or wi <br />Y N <br />Sump Location: TURBINE SUMP X Sump Location: <br />Sune 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 I N TNAT <br />Tank 1— Contents: FILL BUCKET X I Tank 3 —Contents: <br />Tank 2 — Contents: X I Tank 4 — Contents: <br />8 Under -dispenser containment areas are free of water; debris, and hazardous substance. <br />Y N NA <br />Dispenser 1/ 2 X Dispenser 9 / 10 <br />Dis enser 3 / 4 X Dispenser 11 / 12 <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />Dispenser 7 / 8 X Dispenser 15 / 16 <br />". - z . <br />Page I of 2 « - November 2004 <br />9 <br />10 <br />PAPERWORK INSPECTION <br />Monitoring system certification has been completed within past 12 months. <br />Secondary containment tests have been completed within the required timeframe. <br />Y <br />X <br />X <br />11 <br />Spill containment structure(bucket) testing was completed within the past year. <br />X <br />08/22/2011 <br />12 <br />Tank ti tress testing was completed within required timeframe. <br />X <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS <br />X <br />08/22/2014 <br />14 <br />Other required testis maintenance was completed within required timeframe. <br />Test. "61ia1: $S�c. a'° "� e34/2018 <br />X <br />03/24/2015 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y I N NA <br />15 <br />All ility employees have received the required on-the-"ob training within the p4styear. <br />~ <br />X <br />16 <br />All facili em to ees hired within the past 30 Lays have received the required on�,thejob trainin <br />. IX vlr3 <br />Note: Any answer of "N" should be eitplained in the comment section on the following page, and will require <br />follow-up action. <br />". - z . <br />Page I of 2 « - November 2004 <br />