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2098263893 ENGINEERING DEPT. —� 1 :61 a.m. 08-27-2009 10/17 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facili Name: Kaiser Permanente Date: 6/17/09 <br /> Facili Address: 1777 W.Yosemite <br /> City: Manteca ' Zle Code: 95307 <br /> Desi aced UST Operator Conducting the ection: Kenneth`Bud'McCusi <br /> International Code Council Certification#: 5234516-UC IEx2iration Date: 0$/7/2010 <br /> Sipature::it:.W.McgE!# Phone: 925 528-999$ <br /> Y-Yes N=No,P1A=Plot Applicable <br /> Item MONITORING PANEL/ALARM HISTORY Y N I NiA <br /> 1 MonitorinR system is veered on and in ro er o eeatin mode. ❑ <br /> 2 Monitoring system is not currently showing any alarms or warnings., -a_R <br /> 3 Alann history report4og for the previous month is available,and has been reviewed by the <br /> Desi hated UST Op2rator. Attach a Lo&of the alarm history TpelLog to this form if available. <br /> 4 1 Each alarm for the previous month has been responded to appropriately. ❑ ❑ <br /> 6 Sensors located in tank-toe containment sumps have not alarmed in the past month. <br /> Sa 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 he inspected unless a qualified service technician responded <br /> to,and properly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> if sum in ction is moulmd.record results in item 6,below. <br /> EMBEEMEM nil <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> !Vete:Visual in fon of sum s is ordy in sum where an.term has octwrred in the peat month for which there is no semko record. <br /> Y I N Y N <br /> gymg Location: Sump Location: <br /> SUMP Locatlon: gymp Location: <br /> Sump Location: §ymg Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y I N NA Y I N N/A <br /> Tank 1 —Contents:Diesel Tank 3—Contents: Li I Li <br /> Tank 2—Contents:Diesel Tank 4—Contents. <br /> 8 o dispensers are utilized at this facility F4R4E- <br /> PAPERWORK INSPECTION Y I N INA DATE DONE <br /> 9 Monitoring s tem certirication has been completed within past 12 months.- 8129/08 <br /> 10 Secondary containment tests have been completed within the required timeframe. 4107/06* <br /> 11 Spill containment structure(bucket)testing was completed within the past year. 8129/08 <br /> 12 Tank tightness testing was completed within reuired timeframe. 1 I <br /> 13 line ti htness testing was com feted within re uired timeframe. ®. I / / <br /> 14 Other required testing/maintenance was completed within required timeframe. (List fest/maint+enance items below.) <br /> Test/Maintenance: El I El I El II P <br /> Test/Maintenance: 0 ❑ l l <br /> TeWMaintenance: I I <br /> FACILITY EMPLOYEE TRAINING Y N NiA <br /> 15 All facility employees have received the Tguired on-the=ob trainin2 within the past ear. <br /> 16 All facility employees hired within the past 30 days have received the required on-the-job training. <br /> Note: Any answer of"N°should be explained in the comment section,and will require follow-up action. <br /> C® entS:All functions normal,log sheet n,onnal. Owner(KCS PK advises facility working with county <br /> to obtain permit for piping installation,will advise status upon resolution. Pressure line test performed 12/24/08 <br /> (primary,pressure). *Owner to schedule testing'upon resolution with County. System is under design for <br /> abandonment/removal. <br /> Follow up Actions: <br /> Page 1 of 1 November 2004 <br />