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RECEIVED <br />F,,M 13 2017 <br />'Ilk San JoaW1A9"1*LHMLTH <br />Environmental HwaklivDapadment <br />T1868 E. Hazelton_ <br />Stockton, California 95206-6232 <br />11� <br />r r <br />(209) 464-3433 <br />ME a :4. - <br />., ism W. <br />OCT 18 2016 <br />DIRECTOR <br />Donna Heron. RENS <br />�TAHEALTH <br />Robert <br />m4am- <br />Jeff Carruesoo, REHB, RDI <br />Kaley Foley, REBS <br />LkWa Turkatte, REHB <br />Rodney Estrada, REHB <br />Adrienne EAeaemer. REHB <br />'' ' • �' • "' ' ' c <br />[ J 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, aN tank -related appurtenances, streets, adjacent properties (north toward the top of the page), <br />neaalrby 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 utilitles are not included <br />on the site map, you must state in writing that USA Dig will he contacted prior to excavation activities. <br />[ ] 3. Complete pages M "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br />REPAIR PERMIT'. OTE: ILlympling is I ired._jaMI21in9 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 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 maximum review time for Plan Review Is 16 working days from receipt of the 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 />[ ] e. Advance [nspectlon notice of at least 48 hours is required by the Environmental Health <br />Department (EHD). <br />[ ] <br />S. Contractor to Provide: Combustible/Flarnmable 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 regulations 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 Mail on pages 3 & 4 and be shown on the detailed site map. <br />Received Time Apr.13, 2017 2:30PM No,1250 <br />