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...-_........... <br /> i <br /> 2098253893 ENGINEERING DEPT. 0 :42 a.m. 09-10-2010 15/21 <br /> Designated Underground Storage Tank(UST) Operator <br /> Montlty Visual Inspection Checklist <br /> Facility Name: Kaiser Permanente,Manteca Date: 06/17/2010 <br /> Facility Address: 1777 W.Yosemite <br /> City: Manteca Zip Code: 95337 <br /> Desi ated UST Operator Conducting the Inspection: Thomas Hin ston II <br /> International Code Council Certification#: 5301"3-UC Expiration Date: 12/12/2010 <br /> Si ature: Thomas Hin Ston H Phone: 707 295-6066 <br /> Y=Yes N=No NA=Not A plicable <br /> Item MONITORING PANEL/ALARM HISTORY Y N NA <br /> 1 Monitoringsystem is powered on and in proper operating mode. X <br /> 2 Monitoringsystem is not currents showinganalarms or warnings. X <br /> 3 Alarm history report/log for the previous month is available,and has been reviewed by the <br /> Desi ated UST O evator. Attach a co o the alarm histo re ort/lo to thisform i available. X <br /> 4 1 Each alarm for the prAvious month has been responded to appropriately. <br /> X <br /> 5 Sensors located in tank-top containment sumps have not alarmed in the past month. X <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 qualified service technician responded to,and <br /> properly addressed,the cause of the alarm.Attach documentation verifying appropriate service to this report. <br /> !sum ins ection is re wired,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 located properly. <br /> Note:Vestal ins ection of sums is only requi ins s where an alarm has occurred in the past month Lor which there is no service record. <br /> Y N YJ N <br /> Sum Location: Sump Location <br /> Sump Location: Sum Location: <br /> Sump Location: i Sump Location: <br /> 7 Spill containment structures are free of water,debris,and hazardous substance. <br /> Y N INAI Y N NA <br /> Tank 1—Contents: Diesel X Tank 3—Contents: <br /> Tank 2—Contents: Tank 4—Contents: <br /> S No dispensers are utilized at this facility X <br /> PAPERWORK INSPECTION Y N INA I DATE DONE <br /> 9 Monitoring system certification has been comleted within past 12 months. X 08/01/09 <br /> 10 Secondary containment tests have been completed within the required timeframe.* X 08/11/09 <br /> 11 Spill containment structure bucket testing was completed within the past year. X 08/01/0 <br /> 12 Tank tightness testing was conrpleted within re uired timeframe. X <br /> 13 Line tightness testing was completed within required timeframe.* X 08/29/08 - <br /> 14 Other re uired t stin maintenance was completed within required timeframe. List test/maintenance items below.) <br /> Test/Maintenahce: <br /> Test/Maintenance: <br /> Test/Maintenance: <br /> +"FACILITY EMPLOYEE TRAINING Y N NA <br /> 15 All facility employees have received the required on-the-'ob training within the past year.12/11/2009 X <br /> 16 All facilily em to ees hired within the past 30 da s have received the required on-the-'ob training. X <br /> Note: Any answer of"N"should be explained in the comment section,and will require follow-up action. <br /> Comments: No alarm history print out available.Owner(KCS PM)advises facility working with county to obtain <br /> permit for ming installation will advise status upon 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 performed. <br /> Follow up Actions: <br /> R.` Pagel of i November 2004 <br />