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ENVIRONMENTAL HEALTH DEPARTMENT <br />O.t'�u'IN' C <br />SAN JOAQUIN COUNTY flnirsr ervisors <br />Donna K. Heran, R.E.H.S.304 East Weber Avenue, Third Floor Carl Bor an, R.E.H.S. <br />Mike Huggins R.E.H.S., R.D.I. <br />• <br />Director <br />Al Olsen, R.E.H.S. Stockton, California 95202-2708 Douglas W. I lilson, R.E.H.S. <br />•.�, - - �P <br />Program Manager Telephone: (209) 468-3420 Margaret La gorio, R.E.H.S. <br />4cikoa`' <br />Laurie A.Cotulla,R.E.H.S.RobertMcCellon,R.E.H.S. <br />Fax: (209) 464-0138 Mark Barc llos, R.E.H.S. <br />Program Manager <br />APPLICATION FOR PERIMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARnOUS MATERIALS <br />cGENERAL <br />INSTRUCTIONS: <br />mSubmit all information in triplicate. Answer all questions, leaving no blanks. One copy will cthe <br />applicant with comments.hT_2.Include <br />a detailed site map on a separate sheet of paper, showing the location of the tanks(s), p';adjacent <br />the top of the page), nearby septic tanks, leachfrelds,zbuildings, <br />thn <br />properties (north toward <br />underground public utility lines (including water, sanitary sewer and storm sewer)t=- <br />tein <br />of piping from tank to dispensers. If underground utilities are not included on the site map, <br />writing that USA Dig will be contacted prior to excavation activities. <br />Storage Tank Closure Permit". of : m <br />3. <br />Complete page 3, "Application for Underground <br />shall be an independent third party from the contractor. <br />[� 4. <br />Complete page 9, "Authorization to Release". This form must be signed and datell by the <br />r� <br />OWNER/OPERATOR of the facility. <br />5. <br />Submit a "Service Request" form with the appropriate fees, submit completed UPC forms for F cility and <br />A & B forts) and complete page 11, the "Underground Storage Tank Program <br />Tanks (formerly State <br />Fee Worksheet". <br />g [ ] 6• <br />Complete all questions on page 10, the Environmental Health Department (EHD) "Undergroun I Storage <br />those requiring a signature and date of tank rem val. The <br />Tank Disposition Tracking Record" except <br />holder of the permit shall be responsible for ensuring that this form is completed and retume to EHD <br />within 30 days of the tank removal. <br />7. <br />Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potent al hazards <br />Site Safety Plan Guidance Document for specifics. <br />for this specific job site. Refer to the <br />[ ] 8. <br />If facility is located outsid8 oM city limits, submit a "Backfill Excavation Certificate" as required by <br />incorporated City Building Departmea , pursuant <br />the County of San Joaquin Building Department and the <br />to the Uniform Building Code STD 70-11. <br />9. <br />Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division pri r to EHD <br />N' <br />approval of the closure plan. <br />time for Closure Plans is 15 working days from receipt of the adequately completed <br />[ ] 10. <br />The maximum review <br />If deficiencies are identified, an addendum will be required with a $89.00/hour fee and the <br />plan. gross <br />review will begin on the date of resubmittal. <br />[!] 11. <br />Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br />NH 12. <br />Advance inspection notice of at least 48 hours is required by EHD. <br />[ 4(13. <br />Submit Contingency Plan for over-excavation at time of UST removal (if planning to over-exca) ate). <br />2. <br />See "III. SITE MITIGATION' on Page <br />EH 23 046 <br />(Revised 3/15/02) Page 1 <br />