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PUBLIC HEALTH SEVICES SAN JOAQUIN COUNTY x. < ENVIRONMENTAL IIEALTII DIVISION "'• Ernes( M. hujintollo, M.D., M.P.H., Acting health Officer 445 N. San Joaquin Street a P. O. Box 388 a Stockton, CA 95201-0388 �tik ia ' 2119/468-3420 APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS S'T'ORING HAZARDOUS MATERIALS GENERAL INSTRUCTIONS: ( j I. Submit all Information In triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. ( ( 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s), piping, streets,adjacent properties(north toward the top or the page), nearby septic ranks,leachflelds,water wells, buildings, underground public utility tines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not Included on the site ' map, you must state In writing that USA Dig will be contacted prior to excavation activities. Complete page 3, "Application for Underground 'frank Closure Permit". Complete page 9, "Authorization to Relense Analytical Data". This form must be signed and dated by the OWNER/OPERATOR of the facility. I I 5. Submit tine appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet". I I 6. Complete nil questions on page I0, the Public Health Services-Environmental Health Division (PIIS-111113) "Underground Storage Tank Disposition Trucking Record", except those requiring a Signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EI-ID within 30 days of the tank removal. ( ( 7. Submit a "Site Health de Surety 19nn" as an addendum to this application, to address all potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. ( ( 8. it facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-11. ( I 9. Obtain a "Grading and Excnvatimn Permit" from lite City of Tracy Building Division prior to PHS- MID approval of the closure plan. 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completer) plan. It gross deficiencies are identified,an addendum will be required with a$78.00/hour fee and the review will begin on the date of resubmittal. 11. Submit verification of the fire permit from the appropriate fire district at the removal Inspection. ( � 12. Advance insueclion notice of at least 48 hours is required by PHS-EHD. E(1 23 0J7 (Revised 11/1/92) Page t A Division of So"Joaquin Connq. neslih Cue Service"