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Designate Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: <br />SAN JOAQUINGENERAL HOSPITAL <br />I Date: c €' <br />Facility Address: <br />500 WEST HOSPITAL ROAD <br />i ! <br />City: <br />FRENCH CAMP <br />Zip Code: CA 95231 <br />'Designated UST Operator <br />Conducting the Inspection: JESSE BERUMEN <br />International a <br />ouncil C rtification 8014628 -UC <br />Expiration Date: 7/25/2015 <br />Si afore: <br />Phone: 209 367-4800 <br />Y = Yes, N = No, NA = Not Aunlicable <br />Item to MONITORING PANEL / ALARM HISTORY —Y——N NA <br />1 Monitoring system is powered on and in groper operating mode. x <br />2 Monhon <br />ing system is not currently showing any alarms or warnin s. X <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the X <br />Designated UST Operator. Attach a copy of the alarm histo report/lo to thisform if available. <br />4 1 Each alarm for the nrevinus mnnth has hPen rPsnnndPd to nnnr^"ria1- ah Nr <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 pact month must be inspected unless a qualified service technician responded to, and <br />properly addressed; the cause of the alarm. Attach documentation verging appropriate service to this report. <br />I t coon is = record results in item 6, below. <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 ins coon oLsumps is only requi in sunips where an alarm has occurred in the past month or which there is no service record <br />Y N <br />Sum Location: TURBINE SUMP X Sump Location: <br />Sump Location: PIPING SUMP X Sump Location: <br />Sump Location: 11 Sump Location: <br />Y N <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N INA I <br />Y N NA <br />Tank 1 — Contents: FILL BUCKET X Tank 3 — Contents: <br />X <br />Tank 2 — Contents: X Tank 4 — Contents: <br />X <br />8 <br />Under -dip enser containment areas are free of water, debris, and hazardous substance. Sensors are located properl <br />Y N NA <br />Y N NA <br />Dispenser 1/ 2 X Dispenser 9 /10 <br />X <br />Dispenser 3 /4 X Dispenser 11 / 12 <br />X <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />X <br />Dis enser 7 / 8 X Dis enser 15 / 16 <br />ME I III! sommumam <br />PAPERWORK INSPECTION Y N NA <br />X <br />DATE DONE <br />9 <br />Monitoring system certification has been completed within past 12 months. X <br />08/22/2014 <br />10 <br />Secondary containment tests have been completed within the required timeframe. X <br />03/22/2012 <br />11 <br />Spill containment structure ucket testing was completed 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 re uired testin maintenance was completed within required timeframe. <br />�X <br />.. , <br />03/22/2012 <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />—facility <br />Y " N NA w <br />15 <br />16 <br />All employees have received the required on -the job training within the pastyear. <br />All facili em to ees hired within the ast 30 da s have received the required on-the-'ob`trainin <br />X <br />X <br />Auy an—us ua rl ,uuu,u uc cxpinineu III the comment section on the Iollowing page, and will requlrg� q5 ) <br />follow-up action. ell -11 1 <br />Page 1 of 2 November 2004 <br />