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s DIS San Joaquin County <br /> ?° rP Environmental Health Department Linda Linda TOR <br /> � G Turkalte, REHS <br /> ° + 1868 E . Hazelton Avenue <br /> Stockton California 95205 -6232 PROGRAM COORDINATORS <br /> .. > Robert MCClellon, REFS <br /> Jeff Carruesco, REHS, RDI <br /> °qY 1_r nor' P Website : wwws OV.OY lehd Kasey Foley, REFS <br /> J9 9 Adrienne Ellsaesser, REHS <br /> Phone: (209) 468-3420 Rodney Estrada, REHS <br /> Fax: (209) 464-3433 Willy Ng, REFS <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <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 /> [ j 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 appurtenances, streets, adjacent properties (north toward the top of the page) , <br /> nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, sanitary <br /> sewer and storm sewer), and distance of piping from tank to dispensers. If underground 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 3-6, "APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br /> REPAIR PERMIT". NOTE: If sampling is required sampling firm shall be an independent third party from the <br /> contractor performing the work. <br /> I <br /> [ ] 4. Complete page 7, "Authorization to Release". This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> [ j 5. Submit a completed "Service Request" form and "Underground Storage Tank Program Fee Worksheet". <br /> [ ] 6. If performing any excavation activities, and the facility is located outside of the city limits, submit a "Backfill <br /> Excavation Certificate" as required by the San Joaquin County Building Department. If a "Backfill Excavation <br /> Certificate" is required by any incorporated areas (cities) , submit to the appropriate City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11 . <br /> [ j 7. The maximum review time for Plan Review is 15 working days from receipt of the adequately completed plan. If <br /> gross deficiencies are identified, an addendum will be required with a $130.00 per hour fee and the review will <br /> begin on the date of resubmittal. <br /> [ ] s. Advance inspection notice of at least 48 hours is required by the Environmental Health <br /> Department ( EHD) . <br /> [ [ 9. 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 extinguisher(s), and barriers to <br /> secure the area as necessary to minimize traffic and pedestrian interference. It shall be the project manager's <br /> responsibility for compliance with all health & safety regulations and requirements, 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 EHD 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. <br /> EH230038 (revised 12-11-15) 1 I, <br />