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0 <br /> San Joaquin County <br /> Environmental Health Department <br /> 600 East Main Street <br /> �t.r�ra���r�s,RENS <br /> � istoGlCt 3n, California 9521 2-3429 P OGt,AM r COORDINATORS <br /> .' <br /> --...._ _.... <br /> Jeff C.arruer;w,RENS.RE5! <br /> a ev Foley.REHSWebsite-w .sjgov.or /ehc <br /> +iwCF <br /> .� Linn�Phare. (209)466- 420 r <br /> Fax: (20 9)464-0138 EIVED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEC 0 2 2014 <br /> TR FIT OR PIPING REPAIR PERMITNVIRONIMEN7-AL HEALTH <br /> 1 <br /> [] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will e t PAYENT <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 appurtenances, 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 map, you must state in writing that USA Dig will be contacted prior to excavation <br /> activities. <br /> [] 3. Complete pages 3-6, "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT". NOTE: If sampling is required, sampling firm shall bean independent third party from the <br /> contractor performing 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 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 /> [] s. Advance inspection notice of at least 48 hours is required by the Environmental <br /> Health Department(EHD). <br /> [] 9. Contractor to Provide: Combustible/Flammable 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 /> [] 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. All changes to any <br /> work must be described in detail on pages 3&4 and be shown on the detailed site map. <br /> 1 <br />