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E:] <br />r <br />�J <br />Environmental h Department <br />1868 E. Hz ion AivenUC, <br />-STO 95205-6232 <br />Nsr�s ww.sjav rx: rc <br />.J U L_ <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />licant all infmrmen',n in ti'ipilC�?ty t71sVvrtr all C pst'CInE=eaving no blanks One coi3y° will r� retorted to the <br />applicant with C31 T En' <br />t 1 2 Inciude a detailed site map Cr a separate slree" .f paper s�row rich all work to be dorsa Include the location Of <br />h tan3�s(s}, piping, all tanx-related appurtenances streets adjacent properties ktnor-th toward the top of the page). <br />nearby septic tanks leayhfelds, water wells buildngs, .rndergfourro publr litility :lues (including water sanitary <br />Son eLxi r cii1 tCsrr t sewer,, <br />and distance of piping tfOrn tanK tO ;�Isp�nse�i's ;f underground utilities c�"e not included <br />'Ii ultyf Q,1 �, C31 ii i; S? ° i En writing thin, USA Dig w l> be cont cted Prior to xcav 3tion activifies, <br />r Y � �lAi Complete G a p pees .5 APPLICATION r OR UNDERGROUND ST <br />FiEF'Ai{� �'Ef�IT' E'dit°�T � 3{ srr, ��_;s re :sired carr .,lin frrn shail�i;e � • rn � � RAGE 1ANK RETROFIT t�r�frcar�ltti <br />gnY qt rsr C rfQtrr) rr_g_`� _ r r . <br />4 Complete nage "Authorization to Release" € his form rust be signed and cued by the <br />OWNERIOPERATOR of the facility <br />5 Submit a completed `Service Request' form and "Underground Storage Tank Programa Fee Worksheet" <br />E if vatiorr Ceing any excCertificate" <br />acti�ities, and he facility s ocated outside of the city im€ts, submit e "Backfill <br />ertifiate' as required by the San Joagr , aunty uiltfin Cie artrneni <br />Certificate,,, is re(luired by ar9y incorporat€�;d areas (cl, <br />Submit. to theappropriate sty Building Departments, <br />t J 7 The maximum review time fir Plan Revicw s ; woikin days r <br />gross deficiencies are iuentifieb, an addendum will r ra µ o- r£ tEiCi f t?YE r9G . t. )Y U�i(Tt��,tlete €; if <br />begin on the date of resubn vital egui. d wilt. a ;« v per hour fee and the riiew will <br />11 8 Advance insPeCtion flOtice Of at least 48 hosiers is required by the Enviro� I ental Health <br />Department ( HD), <br />i 9. Contractor to Provideornbust€bleiF,ar r� nab,iw � 3 , � �` <br />gas o e€,tor to venry th 0wer Explosive L,mr; (LEL) <br />atmosphere and oxygen level adequate nurnberrs;> and appropriate typelst of e ext ngu,s��y s; and barriers to <br />secure the area as necessary to minimize ,faff,, an, u' e�t•,an nterferet'r� t a r r <br />responsibility for crarrr 'lane e with ail � a',t`° z sales C E ` h be the m nl g <br />p managers <br />ers <br />requirements which Y gulancin,5 and e u � r��rn� <br />sha„ s�r.ct,y p s. inc , ding confined space, <br />adhered tc.- at all flMex during t, of fl,)STi activities COU, -S e .indergrcurd storage tan4 <br />The E i 7 Permit shall be ii(7 SltetL d 9 Il UST perm ;t..r[-iitci <br />11 Any charges in this documerq shall be approved Y � P <br />must be described it) deta�l on Pages 3 4 and be rw th the ail to initiating work hili changes to any work <br />�' shown on tie dL�ts"�;;ed site (ila,"%_ <br />