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RONMENTAL HEALTH DEPARTME <br /> 40 SACT 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: 441-av, DA i'I 6y-\ Date: ? 2?'t9 cr <br /> Title: <br /> Facility Address: I DD IYOSEWt fTl: �l l N 6 PR#: D S l 92 ZZ <br /> Completed Task Comments <br /> Underground Storage Tanks-Facility Form <br /> Underground Storage Tanks-Tank Forms <br /> ®s Financial Responsibility/Letter from Chief <br /> Financial Officer. Due every 12 months <br /> Underground Storage Tank <br /> Monitoring and Response Plans <br /> IY Report#5021 Completed <br /> 2" Designated UST Operator Statement <br /> Best Management Practices(BMP's)for Retail <br /> Gasoline Outlets <br /> ® Board of Equalization UST Storage Fee <br /> Account Number <br /> Monitoring Certification(go over last MC) <br /> Due every 12 months t <br /> C, Spill Buckets <br /> Sensors <br /> Leak Detectors <br /> ® Line Test Requirements(if needed or not <br /> for pressurized piping) <br /> Sensor/Leak Detector failures can have <br /> emergency replacemen mithi oEHDj;rm.t <br /> obtained withiment <br /> All other work must have EHD 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 4a.1jed I i Pw.C - <br /> Go over last date- Due every 36 months r(zb(v 1 M �ed oyI 5-1 z�I®el r j <br /> 0"' California EPA ID number r -7(e( (® <br /> Hazardous waste generator <br /> Fkr Hazardous Materials Management Plan �, , P D v" 0&S <br /> Free UST and CUPA Classes Handout Provided <br /> Consultation by: " 11�t9!(L+•� <br />