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P ULIG-J 1EALT � SERrIC ES ,Q a apt. <br /> SAN .IOAQUIN COUNTY <br /> n: <br /> ENVIRONMENTAL IIEALI'11 DIVISION <br /> Eroesl hl. haJiroolo, M.1)., M.1•.11., Aclhlg health Officer Oki <br /> 445 N. Snn .1"aqui" Slrecl • I . Bax JRA • Stocklan, CA 95201-OJAA Co�G <br /> 2119/468-3420 <br /> At'1'I,ICATIUN II=gR 1'ISlthlt'f'1'U CLUSG <br /> UNUIRGltUUNU S'I'l)IIACI','IANICS S'1S'I'URINI: iIAZARDUUS MA'I'lIt1AIS <br /> UINERAL INS'I'ItUCI'IVNS: <br /> I. Snhmil nil Infonunllon in triplicate, Answer All questions, leaving no blanks. One copy will be <br /> returned to the applicant Willi conitllents. <br /> I� 2. Ilnl'11111e A IIe10nC11 site Ina 11 <br /> OII a sell, <br /> isle sheet of paper,sil(nVing life localioll Of the tanks(%),piping, <br /> stteels, adJacenl ploperfies (uurlh klwnnl the lop of he page),nearby septic tanks,Ienchfields,water <br /> wells, bufidings, underground public utility lines (including water, sanilary sewer and storm sewer), <br /> And distance oI piping honl lank it, dispensers. If underground utilities are not Included on the site <br /> map, you must state In willing that USA big will be contacted prior to excavation activities. <br /> IN 1. Coulpicte page 3, "Applladlon For Underground Tank Closure Permit". <br /> l •t. Cnrnpnctc pnge 9, 'Aarhmiznnon tri Itelense Aunly0cnl Data'. This roti must be signed and dated <br /> by life O1VNfit/0PI tA'I'Olt of the facility. <br /> IVr 5. Submit file npptopllate fees and complete page 11,the"Underground Tank Program Pee Worksheet". i <br /> 6. Complete nil quesfions on page 10, file Public health Services-Environmental Health Division <br /> (PIIS-rl lb) "Underground Slornge Tank Dispoxlllmn '1'racki ng Ree"rd", except those requiring a <br /> siguntore And dale of tank removal. '13nc holder of Isle permit shall be responsible for ensuring that <br /> Ods roan is completed and returned to PI IS-EI ID within 30 days of the talk removal. <br /> i 7. Subnnit n 'Site tlenlrtl h S"rety 1'Inn' m nn addcndam to this application, to address n1i polenllal <br /> I1-.17anls for this specific job site. Itefer to Ole Site Safety Pian Uuidance Document for specifics. <br /> IN 8. if facility is located oulside of the city limits, submit a "Ilncknll rBxenvnllon CertlncAte" as required <br /> by life County of San Joaquin building Department and the Incorporated City Building Dcpartmen(s, <br /> pursuant to (lie Uniform Building Code STD 70-11. <br /> i <br /> i I 9. Obmin a 14"lling "fill Bxcnvn0mn 1•erndt" frons Ole City of Tracy Building Division prior to PHS- <br /> EI ID Approval or the closutc plan. <br /> ( I Ill. The nmxhnunl review line for Closure Pians is 15 working tiny% from receipt of the adequately <br /> congdeled pinn. If gross deficiencies nre identi0ed,an Addendum will be required with a 578.00/hour <br /> fee And Ole review will beghl on the date of resubinillril. I <br /> . <br /> I. Submit vetilicafion of tine fire permit from the appropriate Ore district at the removal Inspection. <br /> I <br /> Advance Insuccllun notice of at leas( 48 hours Is tcgultcd by Pl1S-EHD, <br /> rll 2J (XII (Revised 11/1/92) Page I <br /> A Invtatnn nt San Jnagldn Cnnngt Ilesllh Cue Services <br />