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1 <br />Designat#Jnderground Storage Tank US erator <br />Monthly Visual Inspection Checklis <br />Facility Name: SAN JOAQUIN GENERAL HOSPITAL I Date: <br />Facility Address: 500 WEST HOSPITAL ROAD <br />Ci : FRENCH CAMP Zi Code: CA 95231 <br />Designated UST Operator Conducting the Inspection: JESSE BERUMEN <br />International C Council rtification 8014628 -UC Ex iration Date: 06/06/2016 <br />Signature: Phone: ( 209 ) 367-4800 <br />Y = Yes;' <br />Item <br />MONITORING PANEL / ALARM HISTORY <br />1 <br />Monitoring system is powered on and mi proper operating mode. <br />2 <br />Monitoring system is not currently showing any alarms or warnings. <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by + <br />Designated USTerator: Attach a co o the alarm histo re ort/lo to thisform i <br />4 <br />Each alarm for the previous month has been responded to appropriately. <br />5 <br />Sensors located in tank -top containment sumps have not alarmed in the past month. i <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 guar <br />properly addressed the cause of the alarm. Attach documentation verging appropriate servi <br />if sump inspection is re fired, record results in item 6, below. 11 <br />UST SYSTEM INSPECTION <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substar <br />Note: Visual inspection o sum s is only re utred in sumps where an alarm has occurred i#/ <br />Y N <br />Sump Location: TURBINE SUMP X Sum Locati <br />Sump Location: PIPING SUW X Sum Local` <br />Sump Location: Sum Loce <br />7 <br />Spill containment structures are free of water, debris, and hazardous/ <br />Y N NA <br />Tank 1 -Contents: FILL BUCKET X Tank <br />Tank 2 — Contents: X Tank. <br />8 <br />Under -dispenser containment areas are free of water, debris, aiV <br />Y N NA <br />Dispenser 1/ 2 X <br />Dispenser 3 / 4 X ` <br />. - <br />Dis enser S / 6 X -: <br />Dispenser 7 / 8 X ,. <br />X <br />PAPERWORK INSPECTk Y N NA <br />DATE DONE <br />9 <br />Monitoring system certification has been com leted within past ths. X <br />08/22/2014 <br />10 <br />Secondary containment tests have been completed within the re uir&, timeframe. X <br />03/22/2012 <br />11 <br />Spill containment structure(bucket) testihg was com leted within the past year. X <br />08/22/2014 <br />12 <br />Tank tightness testing was completed within required timeframe. X <br />------------- <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS X <br />08/22/2014 <br />14 <br />Other required testis maintenance was completed within required timeframe. <br />Test. 33r." i98� u�n�ait i2 X <br />03/22/2012 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facility employees have received the required on the-jomg within the past ear. <br />X <br />16 <br />All facility employees hired within the past 30 days have received the re uired on`the-'ob trainin <br />X `;> <br />Note: Any answer of "N" should be eTplained in the comment section on the following page, and will require <br />follow-up action. <br />El <br />TM5 <br />Page 1 of 2 November 2004 <br />