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RECEIVA • RECENED <br /> �l JAN 05 20V San Joaquin County JAN � -9 2017 <br /> ironmental Health Department DIRECTOR <br /> :rr" 1868 E. Hazelton Avenue ENVIP�l°011 -attg t EALTH <br /> a Linda TYr-k <br /> 4immom*mw -W Stockton, California 95205-6232 FROG rolls <br /> i i t 14Ms <br /> Jeff 17w* <br /> '• �a • Kase aFoley,REHS REHS,RDI <br /> 4��Fo `' Website: wwwsjgov.orglehd RodneY Estrada, <br /> Phone: (209)4683420 Willy Ng,REHS REHS <br /> Fax: (209)4643433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> [] 1. Submit all information in triplicafe. Answer all questions, leaving no blanks. One copy will be returned to the <br /> applicant with comments. <br /> [] 2. Include a detailed site map on a separate sheet of paper showing all work to be done. Include the location of <br /> the tanks(s), piping, all tank-related appurtenances, streets, adjacent properties (north toward the top of the page), <br /> nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, sanitary <br /> sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included <br /> on the site map, you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> [] 3. Complete pages 3-6, "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT'. NOTE: If sampling is required sampling firm shall be an independent third Darty from the <br /> contractor performing the work. <br /> [] 4. Complete page 7, "Authorization to Release". This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> [] 5. Submit a completed"Service Request"form and"Underground Storage Tank Program Fee Worksheet'. <br /> [] 6. If performing any excavation activities, and the facility is located outside of the city limits, submit a "Backfill <br /> Excavation Certificate" as required by the San Joaquin County Building Department. If a "Backfill Excavation <br /> Certificate" is required by any incorporated areas (cities), submit to the appropriate City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11. <br /> [] 7. The maximum review time for Plan Review is 15 working days from receipt of the adequately completed plan. If <br /> gross deficiencies are identified, an addendum will be required with a $139.00 per hour fee and the review will <br /> begin on the date of resubmittal. <br /> [] 8. Advance inspection notice of at least 48 hours is required by the Environmental Health <br /> Department (EHD). <br /> [] 9. Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit (LEL) <br /> atmosphere and oxygen level), adequate number(s) and appropriate type(s) of fire extinguisher(s), and barriers to <br /> secure the area as necessary to minimize traffic and pedestrian interference. It shall be the project manager's <br /> responsibility foryg�mpliance with all health & safety regulations and requirements, including confined space <br /> requirement;3hich shall be strictly adhered to at all times during the course of the underground storage tank <br /> (UST) activities. <br /> [] 10. The EHD iq�it shall be on site during all UST permit-related activities. <br /> [] 11. Any changes in this document shall be approved by the EHD prior to initiating work. All changes to any work <br /> must be described in detail on pages 3&4 and be shown on the detailed site map. <br /> EH230038(revised 7-26-2016) 1 <br />