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ALTH SEI�JICES <br /> PUBLrC HE o�avin. <br /> SAN JOAQUIN COUNTY :< <br /> Jo(a KI[ANNA M.U.,M.1'.il. <br /> I With 011ier <br /> P.O. Dox 2009 (1(A)1 Bast IIt,zehon Avcnue) e Soxk,on,Californniin 9520����� <br /> (209) 468-34111 111%�`VN Illnvl,' <br /> AI'1'I,ICA't'ION Fol' "!"RIM <br /> 'f o CLOSE <br /> UNDERGROUNDSTORAGETANKSSTORINGIIALAItllOUS NU- <br /> V 1LS <br /> 1993 <br /> GENERAL INS'1'RUCI'I0NS: ENVIRONMENTAL HEALTH <br /> I- Submit all information is triplicate. One copy is returned to tine applicanpL9001Tek WOS <br /> 2. Include a detailed site map, on a Separate sheet of paper, showing tank location and type, piping, <br /> streets and adjacent properties(north toward the top of the page),location of the nearby septic lanky, <br /> leachfields,wells,buildings,underground public utility lines(includf ng water,sanitary sewer and storm <br /> sewer), and distance of piping [film tank to dispensers. <br /> I I 3. Complete page 3, "Application for Undergroond'r„nk Closure Permit”. <br /> I I 4. Complete page 9, "Authorization to Release Analytical Datn". <br /> 5. Submit the appropriate fees and complete page 11,the"Underground'runk Program Fee Worksheet". <br /> ri. Describe nbslite decontamination techniques applicable, <br /> lrutilized <br /> for Ianspotad( md sr torgefhazrdous stegnratedonsite, and specify tile <br /> parly(ics) who will he disposing of waste generated on site. <br /> 7. Describe un page 5 the method for purging and/or inciting lank(s) and piping. <br /> 9. Describe on page 5 in detail how soil and/or water samples beticalh the lank(s) and piping will be <br /> obtained. <br /> 9. Complete the pertinent section of page Illthe Public health Services-Environmental Health Division <br /> (PI IS-El ID) 'Undergruund 'i'nuk Disposition Tracking Record". 'I'hc holder of lite permit shall be <br /> responsible for ensuring Ilim this fort,, is completed and returned to PHS-EHD. <br /> I11. Submit a "Site Iieallh rF Safety Plan", as an addendum to dlis application, to address all potential <br /> hazards for this specific job site. Refer m) Site Safety Plan Guidance Document for specifics. <br /> II. Submit it "Cnmpnclion Report" as required by the County of San Joaquin Building Department and <br /> it's incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1. <br /> 12. Obtain a "Grading and F,xcovntinn 1'erndl" front the City of'rracy Building Division prior to PHS- <br /> E14D approval of the closure plan. <br /> 13. 'lite 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 S53.00/110ur <br /> fee and lite review will begin on the date of resubmittal. <br /> 14. Submit verification of the fire permit Iron, lite appropriate fire district (prior to scheduling removal <br /> Inspection). <br /> 15. Advance ins ection notice of sit least 48 hours Is required by Public I Icalth Services. <br /> i <br /> Page 1 <br /> A Division of son jimirin Cmmty rtesIth Core Services <br />