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7IRONMENTAL HEALTH DEPARTMEN <br /> SAN JOAQUIN COUNTY <br /> 1868 E.Hazelton Ave. <br /> Stockton,Califomia 95205 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> UST Consultation Checklist <br /> Facility. <br /> Representative: PQM 1 N DF,2 N i A 'j ,,� Date: <br /> Title: SEG R 1:7&-R� <br /> Facility Address: I '3 0 S inJ 1 U S o N WAY ' s-lu e-K7u N.�A SR#: <br /> Completed Task Comments <br /> Underground Storage Tanks-Facility Form Enter into CERS, <br /> Underground Storage Tanks-Tank Forms Enter into CERS <br /> N Financial Responsibility/Letter from Chief <br /> Financial Officer. Due every 12 months Upload document into CERS VQe <br /> Underground Storage Tank <br /> Monitoring and Response Plans Enter into CERS <br /> Report#5021 Completed , <br /> 11 — Designated UST Operator Statement <br /> � P Upload document into CERS � (Oct <br /> Best Management Practices(BMP's)for Retail <br /> Gasoline Outlets <br /> Board of Equalization UST Storage Fee ff <br /> Account Number Enter into CERS <br /> Monitoring Certification(go over last MC) <br /> Due every,12 months <br /> Spill Buckets <br /> Sensors/Leak Detectors <br /> Line Test Requirements(if needed or not <br /> for pressurized piping) <br /> Sensor/Leak Detector failures can have <br /> emergency replacement with EHD permit <br /> obtained within of replacement <br /> All other work must have EHD permit <br /> prior to work being performed <br /> UST owner is responsible to see that EHD Submit UST Owner/Operator written agreement(if <br /> permits are properly obtained. applicable). Can upload document to CERS <br /> Required to create a CERS account at <br /> cers.calepa.ca.gov Provide Lead User Authorization Form <br /> Secondary Containment Requirements <br /> Go over last date- Due every 36 months <br /> bi California A ID b <br /> a number OV,� �n(� C <br /> -� Enter into CERS (Y1 � l Vl� � <br /> Hazardous waste generator Permit <br /> ❑ Hazardous Materials Management Plan Enter into CERS <br /> Free UST and CUPA Classes Handout Provided <br /> Consultation by: ah 0(- I t ritu <br />