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fVIRONMENTAL HEALTH DEPARTME <br /> SAN JOAQUIN COUNTY <br /> 600 E.Main Street <br /> Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> UST Consultation Checklist <br /> Facility <br /> Representative: C� ot, Date: <br /> Title: <br /> Facility Address: S a ( p D PR#: 05 ZI L04 <br /> Completed 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 /> Monitorin and Response Plans <br /> Report#5021 Completed <br /> Designated UST Operator Statement <br /> 0 Best Management Practices(BMP's)for Retail <br /> Gasoline Outlets <br /> 'y� Board of Equalization UST Storage Fee n �e�-, <br /> 1� Account Number J I P <br /> Monitoring Certification(go over last MC) <br /> Due very 12 months <br /> ;t . Spill Buckets <br /> Sensors <br /> Leak Detectors <br /> Line Test Requirements(if needed or not r ' <br /> for pressurized piping) /v I <br /> 4 tx <br /> 1 Sensor/Leak Detector failures can have <br /> emergency replacement with EHD permit <br /> obtained withigu of replacement <br /> All other work must have HD 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 c5 r--c /��►`�� S� �'� <br /> Go over last date- Due every 36 months WQS A C4_ tJ 0UJAX-V__ Wb <br /> California EPA ID number '�(R 4'(d-'l rV1 CL <br /> Hazardous waste generator <br /> Hazardous Materials Management Plan (r u f-r✓1 <br /> f Free UST and CUPA Classes Handout Provided <br /> Consultation by: v t/ "� <br /> ce� S i✓L p rn C�4S C P�e Cho ��l w� -f'o o�n�.v c.^^�����__Cl� r o f l <br /> ��2,r / <br />