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` <br /> San Joaquin County __ <br /> Environmental Health Department <br /> � <br /> ^ �KP�'�no�/mmm��mcrm <br /> �� <br /> ���� E. ������ . . - <br /> �t����� California <br /> PROGRAM COORDINATORS <br /> Stockton, ~—^^^~ =��=�-==�= RvuortmcClrnon esHm <br /> Jeff oon000vv.Rsna.RDI <br /> muuovru�v��s*a <br /> ^*u£0&a�' Website: wnvwvw«jgov~omgymhd Rodney Estrada,ns*a <br /> Phone: (209)468~3420 Willy Ng,es*a <br /> Fax: (209)464-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> [] 1. Submit all information intriplicate. Answer all questions, leaving noblanks. One copy will bareturned hothe <br /> applicant with comments. <br /> [] 2. Include a detailed site mop on a oeponob* 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, |eaohfie|do, water wells, bui|dingn, underground public utility lines (including vvatur, sanitary <br /> sewer and storm aawer). and distance ufpiping from tank todispensers. |funderground 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-G "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT ORPIPING <br /> REPAIR PERMIT". NOTE If sampling is reguired, sampling firm shall be an independent third party from the <br /> contractor performing the work. <br /> [] 4. Complete page 7. "Authorization to Ra|maee''. This form must be signed and dated by the <br /> OWNER/OPERATOR ufthe facility. <br /> [] <br /> 5.Submit a completed"Service Request"form and "Underground Storage Tank Program Fee Worksheet". <br /> [] 6. If performing any excavation motivitiee, and the facility is located outside of the oib/ |imite, submit a ^BomkO|| <br /> Excavation Certificate" as required by the San Joaquin County Building Department. If '`BmckfiKK Excavation <br /> Cmrtificabe" is required by any incorporated areas (oidaa), submit to the appropriate Qty Building Departments, <br /> pursuant 0mthe Uniform Building Code STD 70-11. <br /> [] <br /> 7. The maximum review time for Plan Review is 15 working days from receipt of the adequately completed plan. If <br /> gnuoo deficiencies are idenUfied, an addendum will be required with a $139.00 per hour fee and the review will <br /> begin onthe date ofresubmittal. <br /> [] 8. Advance inspection notice of at least 48 hours is required by the Environmental Health <br /> Department (EHD). <br /> [] S. 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 oxtinguiaher(o). and barriers bo <br /> secure the area as necessary to minimize traffic and pedestrian interference. It shall be the project manager's <br /> responsibility for ounnp|iunco with all health & oafab/ pugu|uUona and nuquivuman<a, 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 EHDpermit shall beonsite during all LIST permit-related activities. <br /> [] <br /> 11. Any changes in this document shall be approved by the EHD prior to initiating work. All changes tuany work <br /> must be described in detail on pages 3&4 and be shown on the detailed site map. <br /> s*u000uo(revised 7'uo-2o1s) 1 <br />