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NOV. 19. 2015 10:26AM N0, 1292 P. 2 <br /> RECEIVED <br /> Sari Joaquin County NOV 19 2015 <br /> Environmental Health Department °oEn� 490NMENTAL <br /> 1868 E_ Hazelton Avenuey{����QQ <br /> PROGRAM COt)K+3�A��3 OADTIIACa1T <br /> Stockton, Geli$Ol'nia 95246-523 Robert McClelion,REH5 <br /> Jeff Carru&s=,RID RDl <br /> Website.- www..sjgov.org/ehdKasey eR~h <br /> u�,aaurxlte ls <br /> Phone, (209)468.3420 Rodney Estrada,RENS <br /> Fax, (209)454-3433 Aorlenne EllwR%ar.RENS <br /> APPLICATION FOR UN'D,F-RGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> [] 1. -Submit all information in-triplicate. Answer all questions, leaving no btanks. 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 /> nQarby ssptic tanks, ieachfields, water welts, 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 U5A Dig will be contacted prior to excavation activities, <br /> (] 3. Complete pages 3-6 "APPLICATION FOR UN08RGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT", NOTtR; If sampling is required, sampling firm shall be an 1nde0gI2dant third party from_thQ <br /> contractor performing the work. <br /> [] 4. Complete page 7, "Authorizadon to release". This totm must be signed and dated by the <br /> OW NEWaPERATOR of the.facility. <br /> [) 5.Submit a completed'Service Request'form and,Underground gaga Tanis Program Fee Workshast". <br /> [) 6. If performing any excavation activities, and the facil►ty is located outside of the city limits, submit a "Backfill <br /> Excavation GertificaW'as required by the San Joaquin County Building Department, if a"Backfill Excavation <br /> Certiftate" is required by any incorporated areas(cities), submit to the appropriate City Building Departments, <br /> pursuant to the Uniform 50iiding Code STD 70-:11, <br /> [] 7,The maximum review time for Plan Reviler is 15 working•days from recejpt of th@ adeguately completed plan. If <br /> gross defjoiencles are ideht?irted, an addendum will be required wfth a $180.00 pe?r 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(EFID), <br /> [] 9. Contractor to Provide: Combustible[Flammable gas detector (to verify the Lower Explosive Limit (1,EL) <br /> atmosphere and oxygen levet), adequate number(s)and appropriate types) 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 /> responsbility for compliance with all health & safety regulations and raquirements, including confined space <br /> requirements, which shall be strictly adhered to at all times during the course of Via underground storage tank <br /> (UST)activlties, <br /> [] 10.The EHD permit shall be on site during all UST permit-related activities_ <br /> [] 11.Any changers in this document shall be approved by the Elio 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 /> 1 <br />