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0VICES PUBLIC HEALTH SER SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer 304 East Weber Avenue, Third Floor • Stockton, CA 95202 209/468-3420 I. GENERAL INSTRUCTIONS: Submit all information in triplicate. Answer all gqueesstti; ns,leav� nooblanks. One copy will be returned to the applicant with comments. �I f the 2. Include a detailed site map on a separate sheet of paper, show ne byng thelocatiseptic tanks, lea4190 chfields, water streets, adjacent properties (north toward the top of the page), y lines (including water, sanitary sewer and storm sewer), and 10 wells, buildings, underground public utilit � distance of piping from tank to dispensers. If underground utilities are not included 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". of : Sam lin firm shall be an independent third party from the contractor. [� 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the OWNER/OPERATOR of the facility. [ 5. Submit the appropriatefees and complete page 11, the "Underground Storage Tan � gr m FeeWorksheet". �yffU�T(3Y/yy(�/NNr�ae l�ssElg�Rt,Q1Gf ] 6. Complete all questions on page 10, the Public Health Services-Environinental Health Division (PHS- EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuri g at this orm is g' 8- tom leted and rem ed to PHS- HD within 30 days of the tank removal. [t}! 7. Su it a "Site Health & Safet Plan" as an adden m to this application, to address all potential azards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. ttt8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" 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. MAI9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD � Y approval of the closure plan. [ ] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a $87.00/hour fee and the review will begin on the date of resubmittal. j 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. [ ] 12. dvance ins ecnon nonce ur a..��• - [l 13. Submit Contingency Plan for over -excavation at time of UST removal (if planning to over -excavate). See "III. SITE MITIGATION" on Page 2. EH 23 046 (Revised 09/21/00) Page 1 A Division of San Joaquin County Health Care Sen -ices