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Designated nderground Storage T (UST) 4perator <br />Monthly Visual Inspection Checkjist <br />NDesi <br />Name: SAN JOA UIN GENERAL HOSPITAL Date: <br />Address: 500 WEST HOSPITAL ROAD Zi Code: CA95231 <br />NCH `CA <br />ated UST erator Conductin the Ins ection: JESSE BERUMEN <br />tion ode Council Certification 8014628 -UC Ex iration Date: 06/06/2016 <br />Phone: (209) 3674800 <br />Item MONITORING. PANEL / AL HIS URz <br />1 Monitorin stem is owered on and in ro er o eratin mode. <br />2 Monitorin s stem is not currently showin an alarms or warnings. <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST erator. Attach a co o the alarm histo re ort4o to this form i av <br />4 Each :alarm for the previous month has been responded to a ro riatel . <br />5 Sensors located in tank -to containment sum shave not alarmed in the ast month. <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 quaked service tech <br />properly addressed the cause of the alarm. Attach documentation verifidnS appropriate service to this report. <br />I i coon is re fired, 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 <br />Note: Visual i coon o su s is on re aired in sum s where an alarm has occurred to the mt month for w <br />Y N <br />Sum Location: TURBINESUMP X Sum Location: <br />Sum Location: PIPING SUMP X Sum Location: <br />Sum Location: <br />Sum Location: <br />7 S ill containment structures are free of water, debris, and hazardous substance. <br />NA <br />Tank <br />Tank 1 - Contents: FILL BUCKET X Tank 3 - Contents: <br />N <br />Tank 2 - Contents: X Tank 4 -.Contents: <br />8 Under -dispenser containment areas are free of water, debris, and hazardous substance. Se <br />Y N NA <br />Dis eraser I / 2 X Dispenser 9 / 10 <br />Dis enser.3 / 4 X Dis eraser 11 / 12 <br />Dis enser S / 6 X Dis eraser 13 / 14 <br />DisDenser 7 / 8 X Dis onset 15116 <br />PAPER <br />o Monitoring systemcertification has been c <br />10 Secon containment tests have been completed <br />11 S ill containment structure(bucket)-tingtwas co <br />12 Tank ti tness testingwas com feted within re uia <br />13 Line ti tness testingwas com feted within re uir <br />14 Other re wired testm maintenance was com feted <br />Test: raleaaaill' ? <br />Test/Maintenance: <br />Test/Maintenance: <br />FACILITY EMPLI <br />15 All facility em to ees have received the re uired <br />1-4-TAll f-c;uty employees hired within the past 30 da <br />Note: Any answer of "N" should be explained in the comment section on the <br />follow-up action. <br />1 within past 12 months. <br />avithin the required timeframe. <br />repleted within the past year. <br />ed time e. <br />:d timeframe. SEE COMMENTS <br />within required timeframe. <br />)YEE TRA G <br />m -the j Db trainin within the t <br />s have received the required yn-the- <br />Page 1 of 2 <br />0 <br />44 <br />udrt'/ l'zU15 <br />03/24/2015 <br />08/17/2015 <br />X -- <br />08/22/2014 <br />page, ana wnt requn q <br />"V-,"7" - s <br />November 2004 <br />