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vobityiil RECEIVE® NOV 0 3 2011 San Joaquin County Environmental Health Department oR�RON NrgLHI�IcrH t�liE$ 1868 E. Hazelton Avenue Linda Tur Stockton, California 95205-6232 Website: www.sjgov.org/ehd Phone: (209) 468-3420 Fax: (209) 464-3433 PROGRAM COORDINATORS Robert McClellon, REHS Jeff Carruesco, REHS, RDI RF Es1�a V E D 'irC 19 2017 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMS VIRONMENTAL HEALTH DEPARTMENT [ ] 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 $139.00 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 be approved by the EHD prior to initiating work. All changes to any work must be described in detail on pages 3 & 4 and be shown on the detailed site map. EH230038 (revised 7-26-2016)