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WesignateodUnderground Storage Tank (UST) Operator <br />Monthly •- • <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL Date: <br />Facility Address: 500 WEST HOSPITAL ROAD T <br />City: FRENCH CAMP Zip Code: CA 95231 <br />Designated UST Operator Conducting the Inspection: JESSE BERUMEN <br />International C Council CeWfication 8014628 -UC Ex iration Date: 06/06/2011 <br />Signature: Phone: 209 367-4800 <br />Y=Yes, 1 <br />Item MONITORING PANEL / ALARM HISTORY <br />1 Monitoring system is powered on and m* proper operating mode. <br />2 Monitoring system is not currently showing any alarms or warnings. <br />3 Alarm history report/log f9r the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy of the alarm history report/logreport1log to thisform if availai <br />4 1 Each alarm for the previous month has been responded to appropriately. <br />[LUSensors 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 quaked service tech; <br />properly addressed the cause of the alarm. Attach documentation verging appropriate service to this report. <br />If sump inspection is reauired 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 gf EnEs is only required in sumps where an alarm has occurred in the past month or wd <br />4XXV <br />Sum Location: TURBINE S Sum Location: <br />Sum Location: PIPING SUMP Sum Location: <br />Sump Location: <br />7 S ill containment structures are free of water <br />Y <br />Sump Location: <br />ebris, and hazardous substance. <br />N 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 NA <br />Dispenser 1/ 2 X <br />Dispenser 3 / 4 X <br />Dispenser S / 6 X <br />DisDenser 7 / 8 X <br />Tank 3 — Contents: <br />Tank 4 — Contents: <br />;. and hazardous sul <br />9/10 <br />11112 <br />13114 <br />15116 <br />Page 1 of 2 Novern r 2004 <br />PAPERWORK INSPECTION <br />Y ItF <br />9 <br />Monitoring system certification has been completed within past 12 months. <br />X <br />10 <br />Secondary containment tests have been com leted within the re wired timeframe. <br />X <br />11 <br />Spill containment structure(bucket) testing was completed within the past year. <br />X <br />08/22/2014 <br />12 <br />Tank tightness testing was completed within required timeframe. <br />X <br />-----®------ <br />13 <br />Line ti ggess testing was completed within required timeframe. SEE COMMENTS <br />X <br />08/22/2014 <br />14 <br />Other required testin maintenance was completed within required timeframe. <br />Test. <br />X <br />03/22/2012 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facZity employees have received the required on-the-job training within the past <br />year. <br />X <br />16 <br />All facilt em to ees hired within the past 30 !!as have received the required o t_job, trainin . <br />Xj <br />Note: <br />Any answer of -"N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />u,,x <br />Page 1 of 2 Novern r 2004 <br />