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s r w rgi C perw - r -e <br />'� C"l --U <br />VIRONMENTAL HEALTH DEPARTMEI4, <br />t 'd Q � S (J��' , SAN JOAQUIN COUNTY ky W <br />1868 E. Hazelton Ave. <br />Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UST Consultation Checklist <br />used el° ( +a r1 � <br />Facility <br />Representative: Date: <br />Title: <br />Facility Address: <br />PR#: &I <br />Completed Task Comments <br />❑ <br />Underground Storage Tanks -Facility Form <br />❑ <br />Underground Storage Tanks -Tank Forms <br />Ll <br />Responsibility/Letter from Chief <br />?inSV✓At�Ge. <br />Financial Officer. Due every 12 months <br />Financial <br />❑ <br />Underground Storage Tank <br />1IV1 ._ M 15Si P� (WKv l We- �k r-10111 <br />Monitoring and Response Plans <br />❑ <br />Report #5021 Completed <br />I <br />❑ <br />Designated UST Operator Statement <br />❑ <br />Best Management Practices (BMP's) for Retail <br />Gasoline Outlets <br />❑ <br />Board of Equalization UST Storage Fee <br />a f �li Caf)OA Pa VkRA. <br />Account Number <br />❑ <br />Monitoring Certification (go over last MC)(�c�- <br />d 064E Wya <br />Due every 12 months <br />❑ I <br />Spill Buckets <br />❑ <br />Sensors <br />❑ <br />Leak Detectors <br />C <br />❑ <br />Line Test Requirements (if needed or not <br />N� <br />for pressurized piping) <br />Sensor/Leak Detector failures can have <br />❑ <br />emergency replacement with EHD permit <br />obtained within of replacement <br />❑ <br />All other work must have EHD permit <br />prior to work being performed <br />❑ <br />UST owner is responsible to see that EHD <br />permits are properly obtained <br />Secondary Containment Requirements <br />sQs Jli�� r` �itl4S �� �Ii <br />❑ <br />Go over last date - Due every 36 months <br />L <br />❑ <br />California EPA ID number <br />❑ <br />Hazardous waste generator <br />Nu ni <br />❑ <br />Hazardous Materials Management Plan <br />❑ <br />Free UST and CUPA Classes Handout Provided <br />Consultation by: <br />)ID <br />