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F'KVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 E. Main Street <br />Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />U$T Consultation Checklist <br />Facility Pf4TPcLI-LD <br />Representative: Date: <br />Q �vt't�, M. i-�- C Date: <br />Title: <br />Facility Address: 4f y 4 VV/ L�,-S C"4 4. a.iL PR#: 2 3161 Z <br />C..Pi�o Task Comments <br />Under ound Storage Tanks -Facility Form <br />Fq ll e c; C S cn <br />Underground Storage Tanks -Tank Forms <br />e,�, <br />Financial Responsibility/Letter from Chief <br />Financial Officer. Due every 12 months <br />Underground Storage Tank <br />1 <br />Cal 1 <br />Monitoring and Response Plans <br />u <br />Report #5021 Completedpw,�1 <br />S <br />Designated UST Operator Statement <br />Best Management Practices (BMP's) for Retail <br />n� r <br />�j <br />Gasoline Outlets <br />'/ <br />Board of Equalization UST Storage Fee <br />Account Number <br />0wC-/ VVW <br />Monitoring Certification (go over last MC) <br />m C-z✓' d '� p <br />e <br />Dueve 12 months' <br />w <br />LYI <br />Spill Buckets <br />eu,-C S <br />Er <br />Sensors <br />I <br />�� <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 with En Re�rrm,it <br />obtained within �Yf �lacem'ent <br />All other work must have EHD permit <br />'pyQvILAI <br />prior to work being performedLIK' <br />UST owner is responsible to see that EHD <br />permits are properly obtained <br />Secondary Containment Requirements <br />�a� �� ty, U 6 9 - <br />Go over last date - Due every 36 months <br />California EPA ID number <br />L <br />1 3 Sz6 v.r� �C'�CO <br />Hazardous waste generator <br />Hazardous Materials Management Plan <br />Lia/1 <br />Free UST and CUPA Classes Handout Provided <br />Consultation by: <br />