Laserfiche WebLink
4807 S. AIRPORT WAY CUSTOMI RV ] t <br /> PUBLIC HEALTH SE ICES o.�Q N <br /> r <br /> SAN JOAQUIN COUNTY < <br /> JOGI KHANNA M.D.NtT H <br /> Heath Officer <br /> P.O. Box 2009 • (1601 East Huelton Avenue) • Stockton, Calflpraa 95201 <br /> (209) 468-3400 <br /> APPLICATION FOR PERMIT TO CLOSE J U L 16 1992 <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> ENVIRONMENTAL HEALTH <br /> GENERAL INSTRUCTIONS: PERMIT/SERVICE$ <br /> [ ] L Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> [ ] 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s), piping, <br /> streets,adjacent properties (north toward the top of the page),nearby septic tanks,leachfields,water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br /> and distance of piping from tank to dispensers. If underground utilities are not included on the site <br /> map,you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> [ ] 3. Complete page 3, 'Application for Underground Tank Closure Permit'. <br /> [ ] 4. Complete page 9, 'Authorization to Release Analytical Data'. This form must be signed and dated <br /> by the OWNEWOPERATOR of the facility. <br /> [ ] 5. Submit the appropriate fees and complete page 11,the'Underground Tank Program Fee Worksheet'. <br /> [ ] 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division <br /> (PHS-EHD) 'Underground Storage Tank Disposition Tracking Record', except those requiring a <br /> signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PHS-EHD within 30 days of the tank removal. <br /> [ ] 7. 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 the Site Safety Plan Guidance Document for specifics. <br /> [ ] 8. If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate' as required <br /> by the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70.11. <br /> [ ] 9. Obtain a 'Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plain <br /> [ ] 10, 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 /> [ ] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [ ] 11 Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> EH 23 007 (Revised 7/10/92) Page 1 <br /> A Division of un loagwn Counry Ho Lh(:uc Xmcn 10 <br />