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5V Location and detail of monitoring/leak detection systems 01�'__ <br /> 6. Location of underground utility lines and vaults <br /> 1. Site address, property lines, scale, ncrth arrow <br /> 8. Surface elevation and loc (90 <br /> ation of 100 year flood plain, if applicable <br /> 9. Equipment summary <br /> M. Required Inspections - New Tank Installations <br /> Each new tank installation must be inspected by the EAat each <br /> stages: . . of the following <br /> 1. installation of secondary containment (liner) system, where applicable <br /> 2. delivery and test of tank on site; excavation complete; placement <br /> exca- <br /> vation of tank in <br /> 3. product line and associated piping - pressure test on lines and tank; overfill <br /> protection devices installed 1 <br /> 4. monitoring system installed; monitcr ports brought to surface <br /> N. I declare that to the best of my knowledge and belief the statements and information <br /> Provided above are correct and true. I understand that information in addition t <br /> that provided above may be needed in order to obtain a permit from the Department <br /> Health Services (DHS) and that no work is to begin on this project o <br /> issued. apartment of <br /> p sect until the permit is <br /> I understand that any changes in design, materials or equipment will void m <br /> construct if prior approval is not obtained. Y permit to <br /> I understand that a permit to operate the underground storage tank s <br /> obtained from the Department within 60 days of putting the system into use.the responsibility of the tank owner, system must be <br /> acceptable tank monitoring and testing schedule, of thtape mi anoannuaateeinclude an <br /> and regular inspection by the DHS. 1 report form, <br /> I will notify the Department of Health Services at least two workingda <br /> in advance to schedule each required inspection. I understand that site <br /> safety are solely the responsibility Ys (48 hours) <br /> responsibility is not shared nor assumed by the n County owner or his agent andathatnd othes <br /> Signature & Title: <br /> Print Name <br /> Telephone ( ) <br /> Date <br /> II-3 <br />