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San Joaquin County <br />Environmental <br />N0 East Main Street <br />Stockton,California95202-3029 <br />L' <br />PROGRAM** v *w, <br />Roben McClellon, <br />.o <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 <br />the 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 <br />of the tanks(s), piping, all tank -related appurtenances, streets, adjacent properties (north toward the top of the <br />page), nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, <br />sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are <br />not included on the site map, you must state in writing that USA Dig will be contacted prior to excavation <br />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 <br />Excavation Certificate" is required by any incorporated areas (cities), submit to the appropriate City Building <br />Departments, 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 <br />plan. If gross deficiencies are identified, an addendum will be required with a $122.00 per hour fee and the <br />review will begin on the date of resubmittal. <br />[ ] 8. Advance inspection notice of at least 48 hours is required by the Environmental <br />Health 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 <br />barriers to secure the area as necessary to minimize traffic and pedestrian interference. It shall be the project <br />manager's responsibility for compliance with all health & safety regulations and requirements, including <br />confined space requirements, which shall be strictly adhered to at all times during the course of the <br />underground storage tank (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 <br />work must be described in detail on pages 3 & 4 and be shown on the detailed site map. <br />1 <br />