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Designate nderground Storage T (UST perat f $_ <br />Monthly Visual Inspection Checklist J1 <br />Facili Name: <br />FacilityAddress: <br />SAN JOA UIN GENERAL HOSPITAL <br />500 WEST HOSPITAL ROAD <br />Date: �. <br />r,t <br />City: <br />FRENCH CAMP <br />ip Code: CA 95231 <br />Designated UST <br />Operator Conducting the Inspection: JESSE BERUMEN <br />International CA4 <br />Council ertification 8014628 -UC <br />Expiration Date: 05/24/2018 <br />Signature: <br />11 <br />Phone:( 209 ) 367-4800 <br />Item <br />H = Hes A=P/O AA=Not <br />MONITORING PANEL / ALARM HISTORY Y r <br />1 I Monitoring system is powered on and in proper o erating mode. X <br />2 MonitoEi!!& system is not currently showing an alarms or warnings. X <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the X <br />Designated UST Operatoi. Attach a copy of the alarm histog report/loreportft to thisform if available. <br />4 Each alarm for the previous month has been responded to appropriately. X <br />5 1 Sensors located in tank -top containment sumps have not alarmed in the past month. X <br />5a I- 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 />If sump inspection is required, record results in item 6. below. <br />M <br />UST SYSTEM INSPECTION <br />6 Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />Note: visual ins ection of sums is only required in sum s where an alarm has occurred in the past month or which there is no service record. <br />Y N I Y N <br />Su!np Location: TURBINE SUMP XSump Location: <br />Sum_p Location: PIPING SUMP X Sum Location: <br />Sum Location: Sum Location: <br />7 Spill containment structures are free of water, debris, and hazardous substance. <br />Y I N I NA <br />Tank 1 — Contents: FILL BUCKET X <br />Tank 2 — Contents: I I X <br />8 Under -dispenser containment areas are free of water, del <br />Y N NA <br />Dispenser 1 / 2 X <br />Dis eraser 3 / 4 X <br />Dispenser 5 / 6 X <br />Dispenser 7 / 8 X <br />Tank 3 — Contents: <br />Tank 4 — Contents: <br />, and hazardous substan6e. Sensors are located <br />9/10 <br />11112 <br />13114 <br />15116 <br />v <br />am <br />Em <br />WM <br />EM <br />MM <br />Page 1 of 2 November 2064' <br />PAPERWORK INSPECTION <br />Y N NA <br />DATE DONE <br />9 <br />Monitoring system certification has been com leted within past 12 months. <br />X <br />08/25/2016 <br />10 <br />Secon containment tests have been completed within the required timeframe. <br />X <br />03/24/2015 <br />11 <br />Spill containment structure(bucket) testing was completed within the past year. <br />X <br />08/25/2016 <br />12 <br />Tank ti htness testis was com leted within required timeframe. <br />X <br />----- ____- <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS <br />X <br />08/27/2015 <br />14 <br />Other required testis maintenance was completed within required timeframe. <br />Test: 'Tri -ani t*j 989 (**kry e4ntiala est testitt due 03/ 4/2018 <br />Test/Maintenance: <br />X <br />03/24/2015 <br />Test/Maintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />All facilit employees have received the required on-the-job training within the past year. <br />X <br />16 <br />Note: <br />All faciliLy em to ees hired within the past 30 days have received the re uired on -*-job trainin . � <br />Any answer of "N" should be explained in the comment section on the followin `p�-ge, and.will require <br />follow-up action. <br />t kl <br />Page 1 of 2 November 2064' <br />