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RECEVV'=D <br /> Li I San Joaquin County SE-p I � 7018 <br /> EnvironmentalHealthDepartmentmn�r � <br /> 1868 E. Hazelton Avenue <br /> ��������K�, ��������MU� �����-���� 'Rob A °=-'- <br /> Jeff conuonov.neHn.Ro| <br /> Website: vvumm.sjgmv.orQ/and Kasey Foley,nEHo <br /> Linda .nsna <br /> Phone: (209)468-3420 Rodney Estrada,nsna <br /> Fax: (209)464-3433 Adrienne snoaeaxn,.nsnn <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> [] 1. Submit all information intriplicate. Answer all questions, leaving noblanks. One copy will bmreturned bothe <br /> applicant with comments. <br /> [] 2. Include o detailed site mop on o 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, |eochfie|do, water wells, bui|dingo, underground public uUUh/ lines (including vvader, sanitary <br /> sewer and storm amwer), and distance ofpiping 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 "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT". � If sampling is required, sampling firm shall be an independent third party from the <br /> contractor performing the work. <br /> [] 4. Complete page 7. "Authorization to Release". This form must be signed and doted by the <br /> OWNER/OPERATOR ofthe facility. <br /> [] 5. Submit acompleted "Service Request"form and"Underground Storage Tank Program Fee VVorhshamt". <br /> [] G. If performing any excavation ocUviUeo, and the facility is located outside of the city Umits, submit o "Backfill <br /> Excavation Certificate" as required by the Son Joaquin County Building Department. If "BackO|| Excavation <br /> Certificate" is required by any incorporated areas (ciUeo), submit to the eppnzphaho City Building Departments, <br /> pursuant tothe Uniform Building Code STD 7U-11. <br /> [] <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 $130D0 per hour fee and the review will <br /> begin nnthe date ofresubmittal. <br /> [] 8. Advance inspection notice of at least 48 hours is required by the Environmental Health <br /> Department (EHD)' <br /> [] S. Contractor to Provide: Combustible/Flammable goo detector (to verify the Lower Explosive Limit (LEL) <br /> atmosphere and oxygen (evu|), adequate number(s) and appropriate type(s) of fire extinguisher(o), 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 & safety regulations and naquinsmento, including confined space <br /> requ\remmnto, which shall be strictly adhered to at all times during the course ofthe underground storage tank <br /> (UST) activities. <br /> [] 1U.The EHOpermit shall beonsite during all LIST permit-related activities. <br /> [] 11. Any changes in this document oheU be approved by the EHD prior to initiating work. All changes to any work <br /> must bedescribed indetail onpages 3&4and beshown onthe detailed site map. <br /> � <br /> 0����� <br /> B <br /> ENV!RONK8ENl7\L <br /> l <br /> H��LTH �FPA�T��E�T <br />