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PUBLIC-aEALTH SERV -- NES <br /> SAM JOAQUIN COUNTY <br /> :a <br /> :< <br /> JO-GI KHANNA M.O.,MY II. <br /> IlcalihOfficcr .. <br /> P.O. Box 2009 0 (1601 East 1welton Avenue) 0 Stockton, California 95201 <br /> (209) 468-3400 <br /> APPLICATION FOR PE TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING 11AZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> ( j t. Submit all Information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> ( j 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s), piping, <br /> streets, adjacent properties (north toward the top of the page), nearby septic tanks,leachfieids,water <br /> wells, buildings, underground public utility lilies (including water, sanitary sewer and storm sewer), <br /> and distance of piping from tank to dispensers. If underground utilities are not included on the site <br /> map, you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> ( j 3. Complete page 3, "Application for Underground 'Tank Closure Permit". <br /> ( j 4. Complete page 9, "Authorization to Release Analytical 'Data". This form must be signed and dated <br /> by the OWNERIOPERATOR of the facility. <br /> ( j 5. Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet". <br /> i <br /> ( j 6. Complete all questions on page to, the Public health Services-Environmental health Division i <br /> (PIIS-EHD) "Underground Storage Tank Disposition Tracking Record% except those requiring a <br /> signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PHS-EIID within 30 days of the tank removal. <br /> ( j 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 /> 8. If facility Is located outside of the city limits, submit a "Backfill Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11. <br /> ( j 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EIID approval of the closure plan. <br /> ( ] 10. Tine maximum review time for Closure Plans is 15 working days from receipt of the adequately <br /> completed plan. If gross deficiencies are identified,an addendum will be required with a S78.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> ( j <br /> it. Submit verification of the fire permit from the appropriate fire district at the removal Inspection. <br /> ( j 12. Advance inspection notice of at least 48 hours is required by PIIS-EHD. <br /> i <br /> 1 <br /> EH 23 007 (Revised 11/1192) Page I <br /> A r]M31on of San Joaquin county Health cart Scrvlccs <br />