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Facility Name: <br />Facility Ad <br />City: <br />Designated UST <br />Item <br />4 <br />5a <br />E <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />SAN JOAQUIN GENERAL HOSPITAL fDate:_ZZ <br />500 WEST HOSPITAL ROAD If r dr <br />fiifN_CH CAMP :�ZipCode- �CA 9�5231 <br />�erator Conduc!LnZ the Ins Pect7io_n-JESSE BERUMEN - <br />Council,Qortification 8014628 -UC Expiration Date: 05/24/2018 <br />PhonS.. ( 209 ) 367-4800 <br />V= <br />N = No. NA = <br />M <br />M <br />tion: <br />J- Location: <br />1'71 <br />ill containment structures are free of water, debris, and hazardous substance. <br />N NA <br />Tank I — Contents: FILL BUCKET <br />Tank 2 — Contents: X <br />8Under <br />-dis enser containment areas are free of water, det <br />D enser 112 Y NA <br />Dis enser 3 4 <br />Dis enser 5 6 <br />Dis enser 7 8 <br />X <br />PAPERWORK <br />9 <br />MOnitOrin SY" certification has been complete <br />10 Second containment tests have been completed <br />=A�* structure <br />f, <br />11 S ill conta iJwas cc <br />12 Tank ti htnesq tegina was c2!npleted within —req <br />uv <br />13 Line ti tness testing was completed within .requin <br />14 Other r aired testin maintenance was com feted <br />Test: <br />Test/Maintenance: <br />YestlMaintenance: <br />Tank 3 Contents: <br />Tank 4 — Contents: <br />and hazardous substance. —Sensors are located <br />i�■ <br />Y N N) <br />9110 X <br />X <br />11112 X <br />X <br />13114 I <br />'— - X <br />1S/16 %r <br />d within past 12 months. <br />within the required timefirame, <br />!n <br />pleted within the past year. <br />ed timefi-ame. <br />A timeframe. SEE COMMENTS <br />within required timeframe. <br />m <br />MIM M I# <br />E <br />EM <br />EM <br />OW41 <br />FACILITY EMPLOYEE - V NA <br />15 1 All facility em to have received the required on-thejob training within the past year. X <br />1 7 <br />[EA I fac�i��es wed M!q!g the past 30 da )T have received the required on:2!S±Lb tra X <br />! 2 �-_ 7X <br />Note: Any answer of "N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Pagel of November 2004 <br />