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mm <br /> � <br /> San Joaquin County <br /> Environmental Health Department o|nsomn <br /> " Donna Heran.REHS <br /> �� <br /> 1868 E. Hazelton Avenue <br /> PROGRAM COORDINATORS <br /> ��t��ckt��n, o�alifork�ia ������0��~��232 nobenwvn|eoon,"sxo <br /> Jeff nu/meo^o.nsoo,RDI <br /> F����' \�mb�i�e� 0/ph� nu^ovFoley,xsoo <br /> ��������^"- - Linda romuxons*o <br /> Phone: (20$)468^3420 Rodney Estrada,nsoo <br /> Fax: (2g9)464^3433 Adrienne co,ueoe,.nsoo <br /> ���| Y����|{l� �[��� U�[������(�N��� �T/������� T��� <br /> ' `. . `-.~,' ` . .~~. " . ~,. ` ^,. ,~°"~, ^^^. ~�,^�^n�^ �� / �^" n ^���~ / ' um^ <br /> RETROFIT OR �K�U�^� �����K�� ����U�U� <br /> nn�~ nn�~�,noo ��n� 0000x��pu���~ox�xnn�� n �~n�^omnnn <br /> 11f 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 8'6 "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT". NW] 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 doted by the <br /> OWN5HX(}PERATORofthe facility. <br /> 5. Submit a completed"Service Request"form and"Underground Storage Tank Program Fee Worksheet". <br /> .� <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. |fa "Backfill Excavation <br /> Certificate" is required by any incorporated areas (cities), submit to the appropriate City Building Departments, <br /> pursuant tnthe Uniform Building Code STD70'11. <br /> .� <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 $130.00 per hour fee and the review will <br /> begin onthe date ofresubmittal. <br /> 8. Advance inspection notice mfatleast 48 hours isrequired bythe Environmental Health <br /> Department (E0D). <br /> ^� <br /> 9. Contractor toProvide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit (LEL) <br /> atmosphere and oxygen |evd). adequate numbor(o) and appropriate type(s) nffire o/(finOuishor(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 LIST 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 />