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RECEIVED <br /> San Joaquin County NOV 12 2015 <br /> Environmental Health Department DIRECTOR <br /> 1868 E. Hazelton Avenue ENVI'F�NI ITAL <br /> Stockton California 95205-6232 hRobert cClell9n,REHltTRs <br /> Stockton, Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RDI <br /> Website: wwwsjgov.org/ehd Kasey Foley,REHS <br /> Linda Tu katte,REHS <br /> Phone: (209)468-3420 <br /> Fax: (209)464-3433 <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 to the <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. 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". NOTE: If sampling is required, sampling firm shall be an independent third party from the <br /> 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 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 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 notice of at least 48 hours is required by the Environmental Health <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 manager's <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 changes to any work <br /> must be described in detail on pages 3 &4 and be shown on the detailed site map. <br /> 1 <br />