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PUBLIC HEALTH SEWS ICES <br />-_- - — -- - SANJOAQUINCOUNi TY Sol/ <br />-- <br />JOG[ KH(1NNA \LD„ M.P.H. OA//l <br />He:dth Officer ,,,� <br />P.O. Box 2009 • (1601 East Hazelton Avrnue) •Stockton, Califo 95201 <br />( 209) 468-3400 <br />APPLICATION FOR PE,RMIT TO CLOSE. <br />GENERAL INSTRUCTIONS: <br />1. Submit all information in triplicate. One copy is returned to the applicant with comments. ° <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 tanks, <br />leachfields, wells, buildings, underground public utility lines (including water, sanitarysewer and storm <br />sewer), and distance of piping from tank to dispensers. <br />of 3. Complete page 3, "Application for Underground Tank Closure Permit". <br />fo' 4. Complete page 9, "Authorization to Release Analytical Data". <br />(� 5. Submit the appropriate fees and complete page 11, the "Undenround Tank Program Fee Worksheet". <br />(] 6. Describe on pages 4 Se 5 the decontamination techniques if applicable, material(s) utilized for rinsate, <br />transportation and/or storage of hazardous waste generated on site, and specify the responsible <br />party(ies) who will be disposing of waste generated on site. <br />[ j 7. Describe on page 5 the method for purging and/or inerting tank(s) and piping. <br />8. Describe on page 5 in detail how soil and/or water �ple�,�Gy@g�.�{te tank(s) and piping will be <br />obtained. Sic <br />TISi��\LVL/��I�I�IJ�19. Complete the pertinent section of page 10, tate Health Services -Environmental Health Division <br />(PHS-EHD) "Underground Tank Disposition Trac��Rl:�cArc�bge holder of the permit shall be <br />responsible for ensuring that this form is complete r ���PHS-EHD. <br />[� 10. Submit a "Site lIealth &Safety Plan", as an ad�nd ation, to address all potential <br />hazards for this specific job site. Refer to Site Sat@ ante Document for specifics. <br />1. Submit a "Compaction 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 Lxcavation Permit" from the City of Tracy Building Division prior to PHS- <br />EHD approval of the closure plan. <br />O 13. The 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/hour <br />fee and the review will begin on the date of resubmittal. <br />(] 14. Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal <br />appointment). <br />15. Advance inspection notice of at least 48 hours is required by Public Health Services. <br />Page 1 <br />A Divi>iun of S -M Joaquin Cnunry HCAih (.9(c .`irviccs <br />