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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". NOTE: If sampling is required, sampling firm shall be an independent third gartyfrom 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 15 working days from receipt of the adequately completed plan. 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 />[ ] s. Advance inspection notice of at least 48 hours is required by the Environmental Health
<br />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 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 />[ J 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 />` J E_,
<br />SEP 3 i 2015
<br />San Joaquin County
<br />Environmental Health Department
<br />DIRECTOR
<br />'•.-T,
<br />Donna Heran, RENS
<br />1868 E. Hazelton Avenue
<br />Stockton, California 95205-6232
<br />PROGRAM COORDINATORS
<br />Robert McClellon, REHS
<br />Jeff Carruesco, REHS, RDI
<br />Website: www.sjgov.org/ehd
<br />Kasey Foley REHS
<br />209 468-3420
<br />( )
<br />LinPhone:
<br />Rodn y Estr d REHS
<br />Rodney Estrada. REHS
<br />Fax: (209) 464-3433
<br />Adrienne Ellsaesser REHS
<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". NOTE: If sampling is required, sampling firm shall be an independent third gartyfrom 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 15 working days from receipt of the adequately completed plan. 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 />[ ] s. Advance inspection notice of at least 48 hours is required by the Environmental Health
<br />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 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 />[ J 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 />` J E_,
<br />SEP 3 i 2015
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