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1� PUBITC HEALTH SEF710ES <br />SAN JOAQUIN COUNTY <br />JOGI KHANNA M.D., M.P.H. a < <br />Health Officer <br />P.O. Box 2009. (1601 East Hazelton Avenue) " Stockton, California 95201 °cJFoa� <br />(209) 468-3400 <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />GENERAL INSTRUCTIONS: <br />[t}� 1. Submit all information in triplicate. One copy is returned to the applicant with comments. <br />Ms- <br />(� 2. Include a detailed site man. on a separate sheet of piper, showing to k location and <br />typ , <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, sanitary sewer and storm <br />sewer), and distance of piping from tank to dispensers. <br />[ 3. Complete page 3, "Application for Underground Tank Closure Permit". <br />4. Complete page 9, "Authorization to Release Analytical Data". <br />[v� 5. Submit the appropriate fees and complete page 11, the "Underground Tank Program Fee Worksheet". <br />[ ] 6. Describe on pages 4 & 5 the decontamination techniques if applicable, material(s) utilized for ansate, <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 />[r]/ 8. Describe on page 5 in detail how soil and/or water samples beneath the tanks) and piping will be <br />obtained. <br />[ ] 9. Complete the pertinent section of page 10, the Public Health Services -Environmental Health Division <br />(PHS-EHD) "Underground Tank Disposition Tracking Record". The holder of the permit shall be <br />responsible for ensuring that this form is completed and returned to PHS-EHD. <br />[.� 10. 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 Site Safety Plan Guidance Document for specifics. <br />[, [/ li. 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 />[ J 12. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br />EHD approval of the closure plan. <br />[ ] 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 $53.00/hour <br />fee and the review will begin on the date of resubmittal. <br />[ J 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 Division of San Joaquin County Health Care Services 0 <br />