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10/28/15 03:44PM BZ Service Station Maintenance 916-572-1050 P.01 <br />1 9 0 <br />Son Joaquin County <br />Environmental Health Departme <br />1868 E. Hazelton Avenue <br />Stockton, California 95205-6232 <br />Website: www.slgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax. (209) 464-3433 <br />DIRECTOR <br />Oorina Herafl, RE-J^JS <br />PROGRAM COORDINATORS <br />R(.�rbert McClellon, REWS <br />Jeff Gattuosck), R�J­IS, Rol <br />Kasey Folay, ftp H$ <br />UDEM Tvrkpne, Rr_-H$ <br />In <br />, I - <br />1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will bereturn to �he <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 lines (including water, sanitary <br />sewer and storm sewer), and distance of piping from tank to dispensers, 11 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 RPTROFIT 'OR PIPING <br />REPAIR PERMIT". If Igni <br />_Ong is <br />_C ( qMk1jarn ig UlAn-kinfte mmdmn <br />contract r J ­ R pLagjfirnL�h <br />hi: Al <br />4, Completo Page 7, "Authorization to Release". This form must be signori and dated by the <br />OWNER/OPERATOR of the facility. <br />5. Submit?) completed "Service Requestfi 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 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 thegge9upt <br />ft!Y 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 />Department (EHD), <br />9. Contractor to Provide: CombustiblelFlammable gas detector (to verity the Lower Explosive .Urnit (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 managees <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. All ChOnges to any work <br />must be described in detail on pages 3 & 4 and be shown on the detailed site map, <br />1. <br />. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <br />