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r 0 PUBLIC HEALTH SERVICES SAN JOAQ fN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer 304 East Weber Avenue, Third Floor • Stockton, CA 95202 209/463-3420 GENERAL INSTRUCTIONS: Submit all information in triplicate. Answer all questions, leaving no blanks. Gne copy will be returned to the applicant with comments. [ j 2. Include a detailed site map on a teoarate sheet of paper, showing the location of the tanks(s), piping, streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water wells, buildings, underground pub.ic utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not inc'..ded on the site map, you must state in writing that USA Dig will be contacted prior to excavation activities. [ ] 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". Not : SamplinK firm shall be an independent third Flarty from the contractor. [ ] 4. Complete page 9, "Authorizatiun to Release". This form must be signed and dated by the OWNER/OPERATOR of the faci iry. (] 5. Submit the appropriate fees and-:omplete page 11, the "Underground Storage Tank Program Fee Worksheet". [ ] 6. Complete all questions on page 13, the Public Health Services -Environmental Health Division (PHS- EHD) "Underground Storage Tauk. Disposition Tracking Record", except dicse requiring a signature and date of tank removal. The hcider of the permit shall be responsible for ersuring that this form is completed and returned to PHS -EH :) within 30 days of the tank removal. [ ] 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer to .ihe Site Safety Plan Guidance Document for specifics. [ ] 8. If facility is located outside of thr eity limits, submit a "Backfill Excavation Co-rtificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-11. i [ ] 9. Obtain a "Grading and Excavation .Permit" from fhe City of Tracy Building Division prior to PHS-EHD approval of the closure plan. [ ] f 10. The maximum review time for Clos.ire Plans is 15 working days from receipt of the zdegdat�ly'completed r" "- plaii.' If gross deficiencies aie idertified, ah'addendum will be iequifed with a $87.00/9our fe 5r3`the review will begin on the date of res.tbmittal. +f [ ] 11. Submit verification of the fire permit from the appropriate fire district at the reaxnrJ inspection. [ ] 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. [ ] 13. Submit Contingency Plan for over-e.c.c avation at time of UST removal (if planning :o over -excavate). See "III. SITE MITIGATION" on Page 2. EH 23 046 (Revised 09/21/00) Page 1 A Division q. -.;an Joaquin County Health Care Services