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[ ] 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 appprtenenop$, streets, adjacent properties (north toward the top of the page),
<br />nearby septic tanks, leachfieids, water wells, buildings, underground public utility lines (including water, sanitary
<br />sewer and storm sewer), and distance of piping from tank to d1wansers. if underground utilities are not included
<br />on the site map, you must state in writing that U6A 019 will be contacted prior to excavation activities.
<br />[] 3. Complete pages - , "APPLICATION FFR UNDaROROUND STORAC,E TANK RETROFIT OR PIPING
<br />REPAIR PERIVIM. N0T : if samolima is required. eamplimca firm shall be an independent third nsrty from the
<br />[ ] 4. Complete page 7, "AuthorE�:ation to Release". This form must be signed and dated by the
<br />OWNER10PERATOR of the fadlity.
<br />[ l 5. Submit a completed "Service Request" form and "Underground Storage Tank Program Fee Workshest",
<br />[ ] 6. If performing any excavation activities, and the facility Is located outside of the city limits, submit a "Backfill
<br />Excavation CertMests" . as required by the San Joaquin County Building Department. If a '1jackflll ExCaVs3tlQh
<br />Certlflcate" is required by any Incorporated areas (cities), submit to the appropriate City Building Departments,
<br />pursuant to the uniform Building Code STIP 70-11.
<br />[ ] 7. The maximum review time for Plan Review Is 15 working days from receipt of the adagu v.comoleted Rlan. If
<br />gross deficiencies are Identified, an addendum will be required with a $125.00 per hour fee and'the review will
<br />begin on the date of resubmittal.
<br />] a. Advpnce inspection notice of at least 4$ houM is required by the Environmental Health
<br />Department (EHD).
<br />[ ] 9. Contractor to Provide: Combustible/Flammable gas detector (to verify the. tower Explosive Limit (LEL)
<br />atmosphere and oxygen level), adequate number(s) and appropriate type(e) of fire extinguisher(s), and barriers to
<br />secure the area as necessary to minimize traffic and pedestrian interference. It shall be, the project managers
<br />responsibility for compliance with all health & safety regulations and requirements, including confined space
<br />requirements, which shall by strictly adhered to at all tirnes during the course of the underground storage tank
<br />(UST) activities.
<br />[ ] 10. The EHO permit shall be on site during ,all UST permit -related activities.
<br />] 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.
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<br />San Joaquin County
<br />Environmental Health Department
<br />DIRECTOR
<br />1868 E, Hazelton Avenue
<br />Donna Heron, REHS
<br />Stockton, California 65205-6232
<br />PROGRAM COORDINATORS
<br />l'�tOatt
<br />Ropert MaClellon, RENS
<br />Jeff Carruesco, REFI$, RDI
<br />Website: wrww.sjgov.org/ohd
<br />Kasey Foley, RENS
<br />Linda Turkatte, RENS
<br />Phone: (2091) 4684420
<br />Fant: (209) 464-3433
<br />[ ] 1. Submit all information in triplicate. Answer all questions, leaving no blanks, One copy will be returned to the
<br />applicant with comments.
<br />[ ] 2. Include a detailed site map on a separate sheet of paper showing all work to be done, Include the location of
<br />the tanks(s), piping, all tank,related appprtenenop$, streets, adjacent properties (north toward the top of the page),
<br />nearby septic tanks, leachfieids, water wells, buildings, underground public utility lines (including water, sanitary
<br />sewer and storm sewer), and distance of piping from tank to d1wansers. if underground utilities are not included
<br />on the site map, you must state in writing that U6A 019 will be contacted prior to excavation activities.
<br />[] 3. Complete pages - , "APPLICATION FFR UNDaROROUND STORAC,E TANK RETROFIT OR PIPING
<br />REPAIR PERIVIM. N0T : if samolima is required. eamplimca firm shall be an independent third nsrty from the
<br />[ ] 4. Complete page 7, "AuthorE�:ation to Release". This form must be signed and dated by the
<br />OWNER10PERATOR of the fadlity.
<br />[ l 5. Submit a completed "Service Request" form and "Underground Storage Tank Program Fee Workshest",
<br />[ ] 6. If performing any excavation activities, and the facility Is located outside of the city limits, submit a "Backfill
<br />Excavation CertMests" . as required by the San Joaquin County Building Department. If a '1jackflll ExCaVs3tlQh
<br />Certlflcate" is required by any Incorporated areas (cities), submit to the appropriate City Building Departments,
<br />pursuant to the uniform Building Code STIP 70-11.
<br />[ ] 7. The maximum review time for Plan Review Is 15 working days from receipt of the adagu v.comoleted Rlan. If
<br />gross deficiencies are Identified, an addendum will be required with a $125.00 per hour fee and'the review will
<br />begin on the date of resubmittal.
<br />] a. Advpnce inspection notice of at least 4$ houM is required by the Environmental Health
<br />Department (EHD).
<br />[ ] 9. Contractor to Provide: Combustible/Flammable gas detector (to verify the. tower Explosive Limit (LEL)
<br />atmosphere and oxygen level), adequate number(s) and appropriate type(e) of fire extinguisher(s), and barriers to
<br />secure the area as necessary to minimize traffic and pedestrian interference. It shall be, the project managers
<br />responsibility for compliance with all health & safety regulations and requirements, including confined space
<br />requirements, which shall by strictly adhered to at all tirnes during the course of the underground storage tank
<br />(UST) activities.
<br />[ ] 10. The EHO permit shall be on site during ,all UST permit -related activities.
<br />] 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.
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