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i tc SAN ��J DQ U (� Environmental Health Department is COUNTY Greotness grows here . APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT [t.]? 1 . Submit all information in triplicate . Answer all questions , leaving no blanks . One copy will be returned to the applicant with comments . [� 2 . Include a detailed site map on a separate sheet of paper showing all work to be done . Include the location of the tanks (s) , piping , all tank-related appurtenances , streets , adjacent properties ( north toward the top of the page) , nearby septic tanks , leachfields , water wells , buildings , underground public utility lines ( including water, sanitary sewer and storm sewer) , and distance of piping from tank to dispensers . If underground utilities are not included on the site map , you must state in writing that USA Dig will be contacted prior to excavation activities . 3 . Complete pages 3-6 , "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT" . NOTE : If sampling is required , sampling firm shall be an independent third Party from the contractor performing the work. 4 . Complete page 7 , "Authorization to Release" . This form must be signed and dated by the OWNER/OPERATOR of the facility . [ 5 . Submit a completed " Service Request" form and "Underground Storage Tank Program Fee Worksheet" . [ ] 6 . If performing any excavation activities , and the facility is located outside of the city limits , submit a " Backfill Excavation Certificate" as required by the San Joaquin County Building Department. If a " Backfill Excavation Certificate" is required by any incorporated areas (cities) , submit to the appropriate City Building Departments , pursuant to the Uniform Building Code STD 70 - 11 . [ ] 7 . The maximum review time for Plan Review is 15 working days from receipt of the adequately completed plan . If gross deficiencies are identified , an addendum will be required with a $ 152 . 00 per hour fee and the review will begin on the date of resubmittal . [ ] 8 . Advance inspection notice of at least 48 hours is required by the Environmental Health Department ( EHD ) . [ ] 9 . Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit (LEL) atmosphere and oxygen level) , adequate number(s) and appropriate type (s) of fire extinguisher(s) , and barriers to secure the area as necessary to minimize traffic and pedestrian interference . It shall be the project manager's responsibility for compliance with all health & safety regulations and requirements , including confined space requirements , which shall be strictly adhered to at all times during the course of the underground storage tank (UST) activities . [ ] 10 . The EHD permit shall be on site during all UST permit-related activities . [ ] 11 . Any changes in this document shall bei roved by the EHD prior to initiating work . All changes to any work must be described in detail on panovnthe detailed site map . MAR Z Z 2019 [zNVIRONMENTAL HEALT14 PERMIRSEROCES 1868 E . Hazelton Avenue I Stockton , California 952051 T 209 46&34201 F 209 464-0138 1 www. sjcehd . com