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To: Page 4 of 10 2015-12-01 00:49:17(GMT) 14153999602 From: rJikola ZAGOROV <br /> REGFivLD <br /> e <br /> NOY 3 0 2015 <br /> Sari Joaquin County <br /> Environn�entai <br /> Health Department INMICENVIRONMENTAL <br /> Donna Hwmw n=DADTAACkiT <br /> 1868 E. Hazelton Avenue <br /> •'', , ' Stockton, California 95205-5232 PRbectMcCOOR.REHS RS <br /> RobettMcCleilon,REHS <br /> r - <br /> Jeff Caruesm,REHS.RDI <br /> Website; Www sjgov.nrg/ehd Kasey Foley,REHS <br /> 209 '468-3420 Undo Turkatte,REHS <br /> Rhone: <br /> ( ) Rainey Estrada,REHS <br /> Fax: (209)464-3433 Adrienne Ellsaesser.REHS <br /> APPLICATION PGR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> [} 1. Submit all information,in triplicate. Answer all questions, leaving no blanks. One copy wilt 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 imation 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, waterwrells,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 PERmrr- 078 If sarnaiing is r2gufreg, sampling firm shall be an indePenden# third Party from the <br /> contractor performing the work. <br /> [] 4. Co.iplete page .7, '!Authorization to Release". This form. must be. signed and dated by the <br /> OWNERIOPEftA Rofthe.facility. <br /> [j <br /> S.Submit a completed Service Request'form and"Underground Storage Tank Program Fee Worksheet". <br /> [3 6. If performing any excavation activities, and the facility is located.outside of the.city limits, submit a "Backfill <br /> Excavation Certificate".as required tzy the Sart Joaquin County Building Department. If'a"Backfin Excavation <br /> Certificate"is required by any incorporated.areas (:'sties), submit to the appropriate City Building Departments, <br /> pursuant to the Uniform.Building-Code 5Tb70-11. <br /> [) 7.The maiximum review time for Flan'Review is 15 wottcing.days from receipt.of the adequately completed Planif <br /> gross deficiencies•are identified, an addendum will be required with a$130.00 per hour fee and the review will <br /> begin on the date.of resubmittal. <br /> () B.Advance inspection notice of at least 48 hours is required by the Environmental Health <br /> Department(EHD). <br /> [] 9.. Contractor to.Provide: GombustiblelFlemmeble gas detector (to verify the tower Explosive Lima (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 for compliance with all health & safely regulations and requirements, including confined space <br /> requirements, which shall be strictly adhered to at all times during.the course of the underground storage tank <br /> (UST)activities. <br /> [] 10.The E!-ID permit shall be on site during all.UST permit-related activities. <br /> [j 11. Any changes in this document,shaft be approved by the EHD prior to initiating work. Ali changes to any work <br /> must be described in detail on pages 3&4 and be shown on the detailed site map. <br /> •l <br />