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Sanioaqwuln County .......... Environmenta! Health Department 1868 E -IaZflton� Avenue StocktonCa�'forma 95205-6232t ,... Phone 209� 468-342C 209 464,341- U 0 0 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT 't 1 1 Submit all information in triplicate Answer all questions, leaving no blanks. One COPY will be returned to the applicant with comments the tanks(s), piping ptic , all tank 0 1 1 2 Include a detailed site map on a separate sheet of Paper showing all work t be done nc ude the location of -related appurtenances streets, adjacent properties (north toward the top Of the page), nearby setanks, leachfields, water wells, buildings underground Public utility lines oncluding wa�eir sanitary sewer and storm sewer) and distance of Piping from tank to dispensers If underground utilities are"not included on the site map, You must state in writing that USA Dig will be contacted prior to excavation actjvitle�s-. 3. Complete pages 3-6, "APPLICATION FOR UNDERGROUND STORAGE TANK R REPAIR PERMIT" NqT9_', If sam)lino is rpri,pnor, --j— ErkOFIT OR PIPING n shall be an iF depengght thirqSAU _fromthe 4. Complete page 7 "Authorization to Release' This form must be signed and dated OWNER/OPERATOR of the facility by the 5 Submit a completed "Service Request* form and "Underground Storage Tank 11 Program Fee Worksheet" 6 If performing any excavation activities, and the facility is located outside,'Cf the City IlMltST submit a "Backfill Excavation Certificate" as -equired by the San Joaquin County Building Department If a "Backfill Excavation Certificate" is required by any incorporated areas (cities), submit to the appropriate City Building Departments. Pursuant to the Uniform Building Code STD 70-11 7 The maximum review time for Plan Review is 115 working days from receipt of the adequately completed plan If gross deficiencies are identified, an addendum will be required with a $130.00 per hour fee and the review will begin on the date of resubmittal 8 Advance inspection notice of at least 48 hours is required epartment (). by the E I nvironmental Health DEHD 9. Contractor to Provide CombuStlble/F ammable gas 'detector (to verify the Lower Explosive Limit (LEL) atmosphere and oxygen level) adequate numbers) and appropriate types) of fire extinguisher(s), I and barriers to secure the area as necessary to minimize traffic and pedestrian interference It shall be the project manager's responsibility for compliance with all health & safety regulations and requirements, including confined space requirements, which shall be strictly adhered to at -111 times during the course of the underground storage tank (UST) activities 10. The EHD permit shall be on site during all LIST permit -related activities. 11. Any changes in this document shall be appf6ved by the EHD prior to initiating work All changes to any work Must be described in detail on pages 3 & 4 and/be shown on the detailed site map