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2098253893 ENGINEERING DEPT. 11• :28 a.m. 08-27-2009 11 /17 <br /> Designated Underground Storage Tank (UST) Operator <br /> Monthly Visual Inspection Checklist <br /> Facility Name: Kaiser Permanente,Manteca Date: 05/21/09 <br /> Facili Address: 1777 W.Yosemite <br /> Ci t Manteca Zig Code: 95337 <br /> Desi ated UST O rator Conducting the Inspection: Thomas Hin ton II <br /> International Code Council Certification#: 5301063-UC Expiration Date: 12/12/2010 <br /> Si tune: •Thomas Hie ston 11 Phone: (70D 295-6066 <br /> Y-Yes N-15 NA=Not Applicable <br /> item MONITORING PANEL/AL HISTORY Y N NA <br /> I Monitorin s tem is owered on and in era statin mode. X <br /> 2 Monitoringstern is not currentl showin an alarnrs or warniu X <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Designated UST Operator, Attach a copy of the alarm histoa MnCdoA to this orm YavailabLS.2 X <br /> 4 Each alarm for the previous month has been res onded to roptiatelY. X <br /> 5 Sensors located in tank-to containment sumps have not alarmed in the Lwt month. X <br /> 5a _ List all tank-top sumps where alarms occurred in the past month: a <br /> a <br /> Note:Sumps.where an alarm has occurred in the past month must be inspected unless a qualffied service technician responded to,and <br /> prpperly addressed,the cause of the alarm.attach documentation verifying appropriate service to this report. <br /> 1 su ina tion is Wred.record results In item 6,below. <br /> vara msr s <br /> UST SYSTEM INSPECTION <br /> 6 Tank-top containment sumps are free of water,debris,and hazardous substance. Sensors are located properly. <br /> Note:Yisual fine tion sumis onlyra fired in s where an alarm has occurred in the Post month for which there is no service record. <br /> Y N Y N <br /> Sum Location: Sum Location: <br /> Sump Location: Sum Location: <br /> �r Sum Location: Sum Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N NA Y N NA <br /> Tank 1—Contents: Diesel X Tank 3_Contents: <br /> Tank 2—Contents: Tank 4—Contents: <br /> 8 to dispensers are utilized at this facility X <br /> PAPERWORK INSPECTION Y N INA DATE DONE <br /> 9 Monitorin stem certification has been completed within ast 12 months. X 08/29/08 <br /> 10 Secon containment tests have been completed within the required timeframe.'" X 04/07/06 <br /> _LL S ill containment structure ticket testigg was completed within the past year. X 08/29/08 <br /> 12 Tank tightness testis was completed within aired timeframe. X <br /> 13 Line tightness test!sS was con feted within 'ted timeframe. X 1 08/29/08 <br /> 14 1 Other required testis maintenance was completed within required timeframe. List dmaintenance items below. <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 1 All facg&EMBloyees have received the r uired on-the-ob trainin within the Bast year.12/16/2008 X <br /> 16 All facili ezn l ees hired within the past 30 da s have received the re aired on-the-'ob txainin . X <br /> Note: Any answer of'IN"should be explained in the comment section,and will require follow-up action. <br /> Comm,eats: No alarm history print out available, Owner KCS=advises facility working with county to obtain <br /> permit for giping installation._will advise status uaon resolution. *Owner to schedule line test upon resolution with <br /> county. 'Owner should notify County re. UST status and inquire whether SB989 testing should be Derformed. <br /> Follow up Actions: <br /> Page I of I November 2004 <br />