Laserfiche WebLink
San Joaquin <br /> .` Environmental Health Department DIRECTOR <br /> ® Hazelton BU Donna Heran,REHS <br /> F• 9 ..: <br /> Stockton, California PROGRAM COORDINATORS <br /> Robert McClellon.REHS <br /> ` Jeff Carruesco,RENS,RDI <br /> Website: .Sjgov.org/ehd Kasey Foley,REHS <br /> Phone: (209)463-3420 Linda Turkatte,REHS <br /> Fax: (209)464-3433 AQf IVED <br /> APPLICATION FOR UNDERGROUND STORAR <br /> RETROFIT OR PIPING REPAIR PERMIT OCT 3 1 2014 <br /> [] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. O <br /> applicant with comments. <br /> DEPARTMENT <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 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 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 PER IT". OTE: If samolina is reaui sapllna firm shall be an Inde ndent third party from the <br /> ontractoLperforming the work <br /> (] . Complete page 7, "Authorization to else". This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> [] <br /> S. 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 /> cavati nifiic e" as required by the San Joaquin County Building Department. If a "Backfill cav ti n <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 adequately completed 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 tic t least 48 hoursis requiredEnvironmental i <br /> th <br /> 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 barriers to <br /> secure the area as necessary to minimize traffic and pedestrian interference. It shall be the project managers <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 /> [j 11.Any changes in this document shall be approved by the EHD 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 /> i <br />