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San, _ii oaquCounty.y
<br />Environrnentel Health Department
<br />1868 L HaZE,ltl-jfl Avenue
<br />»»1205"6 2324 R C) 0; 0 f)
<br />Weosite
<br />2 0 9 46 8- 3 4 2 0
<br />APPLICATION FOR UNDERGROUND STORAGE TANK
<br />RETROFIT OR PIPINO REPAIR PERMIT
<br />Submit all Information in triplicate Answe, ah oljest,ons
<br />applicant wit leaving no blanks One copy,
<br />M Comments will be returned to the
<br />ude a detalleo site rnap on a separate sMeet of paper .Show ng a1i work to be
<br />2 lnc'i
<br />the tanksts), pip,n , a ne
<br />nearby sepvc tanKS. feacriftelds, water we'lis adjacent properties in
<br />9 tank -related appurlenaric.p-s streets adjacc 4 In-clude the location of
<br />blhri toward the top of the page,
<br />bu;idings Under-g(OUrld oubLc utifi , :,nes (including water sanitary
<br />Sewer arid storm; sewerarid distance --f piping fr'om ar*, to dispensers �4
<br />r, u?t, ergrouna 'Jtilihl-�s are 'lot incluclea
<br />USA D1g',P,,J' be ronlacled ex:cavation activities
<br />on the site map, you illu'st Vate in writing that 4L.,
<br />3 Complete pages 3�,6, "APPLICATJOI%j -FOR UNDERGROUND' ST AGE TANK RETROFIT Cr PIPING,
<br />11
<br />REPAIR PERMIT" AC
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<br />sh I) be an ino eqaent rd—)
<br />� trom, t�f)g
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<br />Complete page 7. "Authorization to Release' This
<br />OWNERIOPERATO R of the fa signed be Sig and dated by the
<br />j 5 Submit a Completed "Service Reqoes�l form ark 'Undergr nd Storage Tank Program Fee Worksheet"
<br />6 if performing any
<br />excav@'J0n activities and ;he c i i i ty
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<br />Excavation Certificate,, e la, ,caged outside of the city iirnits. submit a "Backfifl
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<br />red by the San 'Joaquir County EiWdirl
<br />I , 0mr,
<br />'10
<br />g Depamnem, if a "Backfill'Excavation
<br />Certificate- is required! by any incorporated areas (ci` s submit to the appropriate City Buildinq
<br />DUMLJarlt to the Uniform Bodcmg Code STD 70 -" el
<br />Departments,
<br />J 7 The maximurr review time for Plan Rev#ew �s from
<br />Clays
<br />OrR!rg days from receipt of the
<br />gross deficiencies are 1centifiec!, an addenju' pla�,
<br />if
<br />begin on the date of resuornittal m M be required wdh a S1310 00 per riOUr fee and the review mf�
<br />Advance insPeCtion notice of atfast 48 hours is required by the Environmental Health
<br />Department (EHO), I "
<br />9. Contractor to Provide ,-ombUStIbI'eiF &rnrnabje 'to verify the Lower Explosive Limit i,LEil,�
<br />atmosphere and oxygen eve, gas detc'Ctoi ,
<br />secure the area as n 1,� a0equate rli,rnber��S�i and appropriate typei
<br />ecessary to ls� of tire extfriguisher(I-s, and barriers to
<br />minq�rlzt' l'OffiC and bedestriar linter4eren
<br />,c(� It sh&l De the project manager's
<br />respons;biiltY for compliance with all hepitj Safety re-quiations an(j requirem(�,mis, i including confined space
<br />requirements which shall be strictly adhered tr) at ail !Inlr during 'he, cou
<br />rse of the Ji"Idr,-rground storage tank
<br />, I r
<br />10, The EHO permit Shall be ori I site Ourinq a!! UST perrtji,,rer,jfec,., actIv;f1es
<br />11 Any :harqes a,,. tt�iS doc}d'rnenz shall be approvect ,�,y
<br />EflD Pff�), to iniliating �iiio_ r k A i
<br />bedescribed in ,Ieta.1)6n pa, chanf4e$ to any wori<
<br />gef, 3 8, 4 arid be showri on tie detailed site rrao
<br />J UIL 2015
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