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i <br /> � <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY ' , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 1' <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202' L+'F <br /> 209/468-3420 <br /> ii <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> �1 <br /> 1. GENERAL INSTRUCTIONS: a <br /> [ ] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. Epf 5 r to <br /> r <br /> ] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br /> streets <br /> adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water <br /> wells, buildings, underground public utility lines (including water,;sanitary sewer and storm sewer), and <br /> distance of piping from tank to dispensers. If underground utilities are not included on the site map, you <br /> must state in writing that USA Dig will be contacted prior to excavation activities. <br /> Note: Sampling <br /> {] 3. Complete page 3, Application for Underground Storage Tank Closure Permit". g g <br /> e an independent third from the contractor. P Si t� <br /> firm shall b � f3 <br /> P PAY <br /> .. ,i <br /> It <br /> 3 <br /> [ 4. Complete page 9, "Authorization to Release". This farm must be signed and dated by the <br /> OWNER/OPERATOR of the facility. a <br /> i <br /> [� 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> j <br /> j; 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS- <br /> EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br /> and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is <br /> completed and returned to PHS-EHD within 30 days of the tank removal..., <br /> 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential <br /> hazards for this specific job site. Refer to the Site Safety Plan Guidance.Document for specifics. <br /> Ir <br /> I <br /> [ 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by <br /> the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11. <br /> -Aft 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. R <br /> i} <br /> [] 10. The maximum review time for Closure Pians is 15 working days from receipt of the adequately <br /> completed plan. If gross deficiencies are identified, an addendum will.be required with a $78.00/hour <br /> fee and the review will begin on the date of resubmittal. i} <br /> [ l 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> I� <br /> { ] 12. Advance inspection notice of at least 48 hours is re aired by PHS-EHD. <br /> EH 23 046 (Revised 10/19/98) Page 1 q <br /> t' <br /> A Division of San Joaquin Counry Health Carc 6crviccs <br /> I� l <br />