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{ <br />Designate0nderground Storage Tank (UST)ftera <br />Monthly Visual Inspection Checklist <br />Facility <br />Name: SAN JOA UIN GENERAL HOSPITAL Date: !!'0 <br />9 TLI'?.r ZT,,SO <br />FacilityAddress: <br />500 WEST HOSPITAL ROAD <br />Code: CA 95231 <br />f 0-' f <br />City: <br />FRENCH CAMP Zi <br />lfSO <br />' <br />Designated <br />UST operator Conduc#g& the Inspection: JESSE BERUMEN <br />InternationOCoAe Council Certification 8014628 -UC I Expiration Date: 05/2 <br />Si nature Phone: ( 209 367-4800 " <br />MONITORING PANEL / AL HISTORY O�fS""S0 <br />torin s stem is owered on and in ro er o tin mode. <br />,�VO <br />MA <br />torin s stem is not current! show.an alarms or warnin s. <br />by <br />dwLo <br />i /0L <br />history report/log for the previous month is available, and has been reviewed the <br />PNS 3 Sf '�� <br />ted UST Operator. Attach a co o the alarm histo re ort/lo to thisform if a <br />(c <br />1 <br />4 <br />Each alarm for the revious month has been responded to a ro riatel . <br />S! <br />5 <br />Sensors located in tank -to containment sumps have not alarmed in the past month. <br />o _fje# <br />5a <br />_ 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 to ` <br />documentation verifying appropriate service to this repo "; <br />( T <br />properly addressed, the cause of the alarm. Attach <br />I sum inspection is re aired, record results in item 6, below. <br />1000. <br />0® 0f�6I <br />11111111 <br />UST SYSTEM INSPECTION <br />L £� 1 <br />6 <br />Tank -top containment sumps are free of water, debris, and hazardous substance. Sensors <br />Note: visual ins coon o sum s is on re fired in sum s where an alarm has occurred in the past month ors- <br />6 <br />Y N <br />0 <br />Sump Location: TURBINE SUMP X Sump Location: <br />6 ' 4 04 C <br />SumpLocation: PIPINGSUMP X Sump Location: <br />.eossT <br />Sump Location: Sump Location: <br />7 <br />Spill containment structures are free of water, debris, and hazardous substance. <br />___ <br />' 0 <br />Y N NA <br />0 <br />Tank 1— Contents: FILL BUCKET X Tank 3 — Contents: <br />e g ' 62? <br />Tank 2— Contents: X Tank 4— Contents: <br />i y 60, <br />8 <br />Under -dispenser containment areas are free of water, debris, and hazardous subs ce. Sens <br />Y N NA <br />Dis eraser 112 X Dispenser 9 / 10 <br />Dispenser 3 / 4 X Dispenser 11 / 12 <br />Dispenser 5 / 6 X Dispenser 13 / 14 <br />1 Dispenser 7/ 8 X Dis enser 15116 <br />X <br />IMM <br />011111 11M <br />PAPERWORK INSPECTION Y <br />N NA DATE DONE <br />9Monitorin <br />system certification has been completed within past 12 months. X <br />08/17/2015 <br />10 <br />Secondarycontainment tests have been completed within the r aired timeframe. X <br />03/24/2015 <br />11 <br />Spill containment structure (bucket)testing was completed within the past year. X <br />08/17/2015 <br />12 <br />Tank ti htness testingwas completed within required timeframe. <br />X --------- <br />13 <br />Line tightness testing was completed within required timeframe. SEE COMMENTS X <br />08/27/2015 <br />14 <br />Other required testing/maintenance was completed within required timeframe. <br />Test: !2018 X <br />03/24/2015 <br />TesdMaintenance: <br />TesdMaintenance: <br />FACILITY EMPLOYEE TRAINING <br />Y N NA <br />15 <br />1 All facili employees have received the required on-the-'ob training within the past ear. <br />X <br />16 <br />All facili em to ees hired within the ast 30 da have received the r uired o - ..e-'ob trainin . X <br />Note: Any answer of "N" should be explained in the comment section on the followiig..page,,and will require <br />follow-up action. <br />0'. <br />Page 1 of 2 Ek <br />Npvihber,20Q <br />