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ki <br />E <br />E <br />San Joaquin County <br />1868 E. Hazelton Avenue <br />Stockton, California 95205-6232 <br />Website: www.sjgov.orgis <br />Phone: (209) 468-3420 <br />Fax: (209) 464-3433 <br />a a > A <br />04 1 :to] 9 1 iN -141 U I U 10 111:1 1104:3 0 A ,' a IL <br />DEC 0 5 2014 <br />E=4A*L1RF." <br />PA L H Sl 1, <br />PRO <br />Robert McClellan, <br />Jeff Carruesco, RENS, RDI <br />Kasey Foley, REHS <br />Linda Turkatte, RENS <br />1. Submit all information in triplicate. 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 fines (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". OTE If sarrigling is required, sampling firm shall be an independent third 2grtZ from the <br />contractor gerforming the work. <br />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 />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 Departrnent. 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 agMugleN comoleted plan. If <br />gross deficiencies are identified, an addendum will be required with a $125.00 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 />L <br />Department (EHD). <br />9. Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit (LEL) <br />atmosphere and oxygan 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 & safety 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 EHD permit 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. Ali 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 />