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RECEIVED A,`d 13 2017 ECEIVE <br />San JoaqWVkA9#9fXL HEALTH <br />Environmental Holliliftliv0spadment <br />1868 E. Hazelton Avenue <br />Stockton, 95205-6232 <br />Webslte: .sJgov.org/ehd <br />Phone., () 468-3420 <br />Fax: (208) -3433 <br />OCT 18 2016 <br />DIRECTOR <br />Donna Heran, REHS <br />gTAL HEALTH <br />Robert <br />Jeff Carrue®co, REH8, RDi <br />Kasay Foley, RENS <br />Linda Turkatte, REHS <br />Rodney Ealrads, REHS <br />Adrienne EAaaeeaer. RENS <br />�i .. 1, + !� � . •. •w � � <br />UAIONJA <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 />(J 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 utlllties' 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'. kgM If sgm lid is reguired. sampling firm shall be an independent third party from the <br />contractar performing the work. <br />[ ] 4. Complete page 7, "Authorization to Release". This form must be signed and dated by the <br />OWNERIOPERATOR of the facility. <br />[ ) 3. 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 Excavation <br />Certificate" Is required by any Incorporated areas (cities), submit to the appropriate City Building Departments, <br />pursuant to the Uniform Building Code STD 70-11. <br />[) 7. The meximum review time for Plan Review Is 15 working days from receipt of the pderguately camoieted_12liap, If <br />gross deficiencies are Identified, an addendum will be required with a $130.00 per hour fee and the review will <br />begin on the date of resubmittal, <br />[ j e, Advance Inspection notice of at [east 48 hours Is required by the Environmental Health <br />Department (EHD). <br />[ J 9. Contractor to Provlde; 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 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 regulatlons 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 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 />Received Time Apr -13. 2017 2:30PM No.1250 <br />