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DocuSign Envelope ID:57852BDB-FD2B-4170-B5C8-435307C98954 <br /> SAN 1 OA Q U I N Environmental Health Department <br /> COUNTY <br /> Crrearness grows bf-rr. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> [] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to 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 <br /> location of the tanks(s), piping, all tank-related appurtenances, streets, adjacent properties (north toward <br /> the top of the page), nearby septic tanks, leachfields, water wells, buildings, underground public utility <br /> lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. <br /> If underground utilities are not included on the site map, you must state in writing that USA Dig will be <br /> contacted prior to excavation activities. <br /> [] 3. Complete pages 3-6, "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR <br /> PIPING REPAIR PERMIT". NOTE: If sampling is required, sampling firm shall be an independent third <br /> Party from the 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 <br /> Worksheet". <br /> [] 6. If performing any excavation activities, and the facility is located outside of the city limits, submit a <br /> "Backfill Excavation Certificate" as required by the San Joaquin County Building Department. If a <br /> "Backfill Excavation Certificate" is required by any incorporated areas (cities), submit to the <br /> appropriate City Building 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 <br /> completed plan. If gross deficiencies are identified, an addendum will be required with a $152.00 per <br /> hour fee and the review will begin on the date of resubmittal. <br /> [] 8. Advance inspection notice of at least 48 hours is required by the <br /> Environmental Health Department (EHD). <br /> [] 9. Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit <br /> (LEL) atmosphere and oxygen level), adequate number(s) and appropriate type(s) of fire extinguisher(s), <br /> and barriers to secure the area as necessary to minimize traffic and pedestrian interference. It shall be <br /> the project manager's responsibility for compliance with all health & safety regulations and requirements, <br /> including confined space requirements, which shall be strictly adhered to at all times during the course of <br /> the 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 <br /> any work must be described in detail on pages 3 &4 and be shown on the detailed site map. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />