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• <br />CJ <br />San Joaquin County <br />Environmental Health Department <br />co nlRr c ►oR <br />2 ,nom G Owwaltnan kl.M <br />600 East Main Street <br />Stockton, California 95202-3029 PROGRAMCOOROINArORS <br />Rubort McCln4nn, RIJIS <br />J#J" Ca"U(I'"'Or REHS.RUI <br />Ka-wacq�ll IS <br />i F a,0 a`P Website: www.sf yov,or91ehd 1 h n,iTu k ►iap ftf H <br />Phone: (209) 468-3420 <br />Fax: (209) 464-0138 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />1_ Submit all information in triplicate Answer all questions, leaving no blanks One copy will be returned to <br />the 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 <br />of the tanks(s), piping, all tank related apputtemmces, streets, adjacent properties (north toward the top of the <br />page), nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, <br />sanitary sewer and storm sewer), and distance of piping from tank to dispensers If underground utilities are <br />not included on the site rnap, you rrntst state in writing that USA Dig will be contacted prior to excavation <br />activities. <br />' 3. Complete pages 3-6, "APPLICATION FOIR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br />REPAIR PERMIT'. NOTE: If sampling is equired, sampling firm shall be an independent_third #arty From the <br />contractor performing the work. <br />/j 4. Complete page 7, "Authorization to Release". This form must be signed and dated by the <br />OWNER/OPERATOR of the facility. <br />5. Submit a completed "Service Request" form and "Underground Storage Tank Program Fee Worksheet" <br />.a r 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 <br />Excavation Certificate" is required by any incorporated areas (cities), submit to the appropriate City Building <br />Departments, 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 <br />Ian. If gross deficiencies are identified, an addendum will be required with a $122 00 per hour fee and the <br />review will begin on the date of resubmittal <br />8. Advance inspection notice of at least 48 hours is required by the Environmental <br />Health Department (EHD). <br />9. Contractor to Provide: Combustible/Flarrnrnable 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 <br />barriers to secure the area as necessary to minimize traffic and pedestrian interference. It shall be the project <br />manager's responsibility for compliance with all health & safety regulations and requirements, including <br />confined space requirements, which shall be strictly adhered to at all times during the course of the <br />underground storage tank (UST) activities. <br />X 10. The EHD permit shall be on site during all UST permit -related activities <br />1 1 Any changes in this document shall be approved by the EHD prior to initiating work Ail changes to any <br />work must be described in detail on pages 3 & 4 and be shown on the detailed site map <br />