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OHtONMENTAL HEALTH DEPARTMEO <br /> SAN JOAQUIN COUNTY <br /> 1868 E.Hazelton Ave. <br /> Stockton,California 95205 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> UST Consultation Checklist <br /> Facility n Date: c3 20 <br /> Representative: �aT C/�I_ 5� 4� <br /> Title: C7wv�c✓ <br /> Facility Address: LA 2.o r ti• Yr TQ rA"Ie-- cnVC dMo,Acm , c—* g S 33 j—SR#: 00 O q <br /> Compined Task Comments <br /> Underground Storage Tanks-Facili Form Enter into CERS t )A <br /> Under ound Stora a Tanks-Tank Forms Enter into CERS (OUQC <br /> �/ Financial Responsibility/Letter from Chief <br /> 5� Financial Officer. Due eve 12 months Upload document into CERS 111 L'jR�Lt <br /> Underground Storage Tank <br /> Monitoring and Response Plans Enter into CERS <br /> Report#5021 Completed <br /> Designated UST Operator Statement Upload document into CERS <br /> Best Management Practices(BMP's)for Retail <br /> Gasoline Outlets <br /> Board of Equalization UST Storage Fee <br /> Account Number Enter into CERS (Wk Q� <br /> Monitoring Certification(go over last MC) � 14 _� (� I� <br /> Due eve 12 months e - <br /> �r Spill Buckets <br /> Sensors/Leak Detectors <br /> Line Test Requirements(if needed or not <br /> y" for pressurized piping) <br /> Sensor/Leak Detector failures can have <br /> Cd 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 /> �y UST owner is responsible to see that EHD Submit UST Owner/Operator written agreement(if <br /> J ' permits are properly obtained. applicable). Can upload document to CERS <br /> C Required to create a CERS account at <br /> X� cers.calepa.ca.gov Provide Lead User Authorization Form <br /> Secondary Containment Requirements ' A •J) r , yl „,A —y p ( Q ,4 <br /> Go over last date- Due every 36 months VG�O�(/ C40Vt cY Ipt CKl �h <br /> California EPA ID number Enter into CERS <br /> Hazardous waste generator Permit <br /> Hazardous Materials Management Plan Enter into CERS <br /> Free UST and CUPA Classes Handout Provided . 93 <br /> Consultation by: T —� <br />