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0 RECEIVEC <br />San Joaquin County <br />Environmental Health Department <br />1868 E. Hazelton Avenue <br />Stockton, California 95205-6232 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 464-3433 <br />aX130NMENTAL. <br />PROGRAM COORDINATORS <br />Robert mcoiemm.nsoa <br />Jeff canv,sco.Re*S.RDI <br />xauoyFoley. nEnO <br />Linda rvmaxe.nsae <br />[] 1. Submit all information in triplicate. Answer all questionm, leaving no blanks. One copy will be returned tuthe <br />applicant with comments. <br />[] 2.Include udetailed site map onaseparate sheet ofpaper showing all work tobadone. Include the location uf <br />the nks(s) all tank -related appurtenances, streets, adjacent properties (north toward the top ofthe pagn), <br />nearby septic tanks, |eochfiekdo, water wells, bui|d}ngm, underground public utility lines (including water, sanitary <br />sewer and storm aewer), and distance nfpiping from hank 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". � If sampling is reguired, sampling firm shall be an independent third party from the <br />contractor erforming 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 ��heet". <br />[] G. 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 is16working days from receipt of the adecluately completed glen. If <br />gross deficiencies are |dendOed, 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 />[] 0. Contractor to Provide: Com gas detector (to verify the Lower Euplonive^Umd (LEL) <br />atmosphere and oxygen level), adequate number(s) and appropriate type(s) of fire extinguisher(s), and barriers to <br />secure the area ao necessary hzminimize traffic and pedestrian interference. |tshall bo the project manager's <br />responsibility for compliance with all health 8 safety regulations and naquirements, including confined apmoa <br />nequiramentm, which shall be strictly adhered to at all times during the course of the underground storage tank <br />(UST) activities. <br />[} 1O.The EHDpermit shall beonsite during all LIST permit -related activities. <br />[] 11.Any changes inthis document shall beapproved bythe EHDprior tuinitiating work. All changes toany work <br />must be described in detail on pages 3 & 4 and be shown on the detailed site map. <br />0 <br />