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' <br /> S A N tJ 0 A 011 N <br /> Environmental HeaUth Department <br /> ~ --COUNTY— '+=� —= �� �~�= <br /> ' RL <br /> '. '– r � � ��, � 0�/co/ne,� grows �o,c� � �� y� `� . �= *� <br /> � <br /> APPLICATION FOR UNDERGROUND STORAGE TANK'` <br /> RETROFIT OR PIPING REPAIR <br /> [TH <br /> [] 1. Submit all information intriplicate. Answer all questions, leaving noblanks. One copy will bereturned <br /> to 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 <br /> location ofthe tankm(o). piping, all tank-related appudenonuao, otnaatu. adjacent properties (north toward <br /> the top of the paQe), nearby mopUu tanks, |eauhfie|du, water wells, bui|dinga, underground public utility <br /> lines (including water, sanitary sewer and storm sewad, and distance ofpiping from tank to dispensers. <br /> If underground utilities are not included on the site nnop, you must state in writing that USA Dig will be <br /> contacted prior toexcavation activities. <br /> [] 3. Complete pages 3-8. "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR <br /> PIPING REPAIR PERM|T" <br /> Party from the contractor performing the work. <br /> [] 4. Cump|ohu page 7. "Authorization to Rm|masm" This form must be signed and dated by the <br /> OWNER/OPERATOR ofthe facility. <br /> [] 5. Submit o completed ^8an/ica Raquaat" form and "Underground Storage Tank Program Fee <br /> Worksheet". <br /> [] 6. If performing any excavation aotividau, and the facility is located outside of the oih/ |inmibu, submit o <br /> "Bmokfii| Excavation Certificate" as required by the Son Joaquin County Building Department. If <br /> "Backfill Excavation Certificmtm'^ is required by any incorporated areas (uitieo), submit to the <br /> appropriate City Building 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 <br /> plan.completed If gross deficiencies are identifiad, an addendum will be required with a $152.00 per <br /> hour fee and the review will begin onthe date ofresubmittal. <br /> [] 8. Advance inspection notice of at least 48 hours is required by the <br /> Environmental Health Department (EHD)' <br /> [] 9' Contractor to Provide: Combustible/Flammable gas detector (to verify the Lower Explosive Limit <br /> (LEL) atmosphere and oxygen level), adequate number(s) and appropriate type(s) of fin* axtinguioher(o). <br /> and barriers to secure the area as necessary to minimize traffic and pedestrian interference. It shall be <br /> the project manager's responsibility for compliance with all health & safety regulations and requinurnents, <br /> including confined space requirements, which shall be strictly adhered to at all times during the course of <br /> the underground storage tank(UST) activities. <br /> [] 10. The EHOpermit shall beonsite during all LIST permit-related activities. <br /> [] <br /> 11. Any changes in this document shall be approved by the EHD prior to initiating work. All changes tn <br /> any work must be described in detail on pages 3 &4 and be shown on the detailed site map. <br /> 1808E. Hazelton Avenue | Stockton, California 952O5 | T 200468-34201 F 2084G4-U138 1 www.sjcehd.com <br />