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VH2ONM ENTAL 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: Date: �- <br /> Title: MG"gRQe!Lr SAZ.���`Z <br /> Facility Address: NQ ' Moik SR#: a <br /> Completed Task Comments <br /> Underground Storage Tanks-Facility FormaEnt <br /> to CERS <br /> Underground Storage Tanks-Tank Formsto CERS <br /> Financial Responsibility/Letter from ChiefY>n �j`0V1 <br /> Financial Officer. Due eve 12 months doe ent into CERS S h I� V)aj <br /> Underground Storage Tank n <br /> Monitoringand Response Plans Enter into CERS RC rn Q V 1 d ec7 <br /> Report#5021 Completed <br /> —� ❑ Designated UST Operator Statement Upload document into CERS �0 V <br /> Best Management Practices(BMP's)for Retail <br /> Gasoline Outlets <br /> Board of Equalizati9n UST Storage Fe <br /> Account Number Sk,l Enter into CERS - Cra O <br /> Monitoring Certification(go over last MC) <br /> Due ery 12 months <br /> Spill Buckets <br /> l Sensors/Leak Detectors <br /> Line Test Requirements(if needed or not <br /> for pressurized piping) <br /> Sensor/Leak Detector failures can have <br /> C� emergency replacement with EBD 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 EBD 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 /> California EPA ID number �\i)QQ G[) Enter into CERS V p <br /> Hazardous waste generator Permit <br /> 6( Hazardous Materials Management Plan Enter into CERS <br /> Free UST and CUPA Classes Handout Provided F <br /> Consultation by: �,Q� I V <br />