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"WIRONMENTAL HEALTH DEPARTMEP' <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor <br /> Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> UST Consultation Checklist <br /> Facility <br /> Representative: �►a �land(Gf Date: <br /> Title: OlAjo IV <br /> Facility Address: ��t� N. ��vac�O 5�, PR#: � <br /> Comp ed Task Comments <br /> Underground Storage Tanks-Facility Form <br /> Underground Storage Tanks-Tank Forms <br /> Financial Responsibility/Letter from Chief <br /> Financial Officer. Due every 12 months <br /> Underground Storage Tank <br /> Monitoring and Response Plans <br /> Report#5021 Completed <br /> Designated UST Operator Statement <br /> / Best Management Practices(BMP's)for Retail <br /> V Gasoline Outlets <br /> Board of Equalization UST Storage Feed u MY16V r' o�j�-A4✓1 <br /> Account Number <br /> / Monitoring Certification(go over last MC) <br /> Due very 12 months <br /> Spill Buckets <br /> Sensors <br /> Leak Detectors <br /> Line Test Requirements(if needed or not <br /> for pressurized piping) <br /> Sensor/Leak Detector failures can have <br /> emergency replacement witli EHD permit <br /> obtained within r!!jreplacement <br /> V All other work must have VHD permit <br /> prior to work being performed <br /> UST owner is responsible to see that EHD <br /> permits are properly obtained <br /> Secondary Containment Requirements <br /> Go over last date- Due every 36 months <br /> California EPA ID number �'Av`5 �,nL v 0 ,►� <br /> Hazardous waste generator <br /> Hazardous Materials Management Plan A4V"'C Ow'ht✓ �N '� �"° k <br /> Free UST and CUPA Classes Handout Provided <br /> Consultation by: <br /> i <br />