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HEGEIVED <br /> MAR 0 4 2016 <br /> San Joaquin County <br /> ENVIRONMENTAL <br /> Environmental Health Department DIM;kw r)l:0ART.APr-:l <br /> 1868 E. Hazelton Avenue Dorma Herarl,RENS <br /> Stockton, California 95205-6232 PROGRAM COORDINATOR8 <br /> R Robed McQellon,REHS <br /> Jeff Carruesco,REHS,RD) <br /> We4slte: wVM',sJ90V.0rg/ehd Kasvy Foley,REHS <br /> Phone: (209)468-3420 Linda Turkatte,REHS <br /> Fax, (209)464-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAID 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 sower), 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". 90!M If sampling is required, sam2ling firm shall be an indegendenf third art from the <br /> contractor paL[girmingi.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 <br /> Certificate" is required by any incorporated areas (cities), so Excavation <br /> 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 rej,'eipt of the a Ile uatel cam Pleted plan, If <br /> gross deficiencies are Identified, an addendum will be required with a $1per r 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 tYPP(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 <br /> (UST)activities. times during the course of the underground storage tank <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 /> J <br /> .. ......... <br />