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11/23/15 11;52AM BZ Service Station Maintenance 916-572-1050 p.02 <br /> San Joaquin County <br /> DIRECTOR NOV 2 3 2015 <br /> Environmental Health Department <br /> Df>nna loran,REHS <br /> 1868 E. Hazelton Avenue <br /> PROOR <br /> Stockton, California 95205-6232 6"GNMENTAL <br /> RQ?X-d McUOUMMOAPTRAPKIT <br /> .1off Carruesco,RrHS,RN <br /> Website, www.9J9ov.org/ehd K,,say i°oley.RT <br /> UrWa Turkatte. <br /> Phone., (209)46a-3420 <br /> Fax. (209)464-3433 <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 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, 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 utilities 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". Lq if samOng i.1 reeit fired, <br /> &L <br /> Shall be an Inoop ii;LenLtt iird party from the <br /> eorttraot9r.o�rm„,ing„thg work. <br /> 4, Complete page 7, "Authorization to Release”. This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> J 5,Submit a completed"Service Request'form and "Undarground Stqrage Tank Program Foo Workshost', <br /> 6. if performing any excavation activities, and the facility is located outside of the city limits, submit a "Backflil <br /> Excavation Certificate" as required by the San Joaquin County Building Department. If a "BacRfill.Excavation <br /> Cortifleate" is required by any Incorporated areas (cities), submit to the appropriate City Building Departments. <br /> pursuant to the Uniform Building Code$To 70-11, <br /> 7,Thern review time for Plan Review Is 15 working days frorn receipt of the jdjqgljTjy�� <br /> M-1ximuql Ui1qjgg_p_1an. If <br /> gross deficiencies are Identified, an addendum will be required with a $125.00 per hour fee and the review will <br /> begin on the date of resubmittal. <br /> 8. Advance inspection notice of at least 48 hours is required by the Environmental Health <br /> Department (EHD). <br /> 9. Contractor to Provide: Corribustible/Flammable gas detector (to verify the Lower Explosive ,Limit (LEL) <br /> atmosphere and oxygen level), adequate number(s)and appropriatetype(s)of fire extinguisher(s), and barriers to <br /> secure the area as necessary to minimize traffic and pedestrian intOrteronce. It shall be the project managers <br /> responsibility for compliance With all health & safety regulations and requirements, including c=fined 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 LIST 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 end be shown on the detailed site map. <br /> ............................. <br />