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DEC- 6-95 WED 14:36 KLEINFELDER FAX N0. 2099480621 P. 08/20 PUBLIC HEALTH SER`�CES ,vaom''s��. SAl`t JOAQUIN COUNTY ' N blA r ENVIRONMENTALI•IFALTH DIVISION � ActingHealth Officer Ernest �f. Fujimoto, M.D•, [ P•H , c- �o 445 V. San Ioaquin Street r P. 0. Bos 383 • Stockton, C.-k 95201-0588 :091468-3430 ..1'Pr ICt,,T1OH FOR PERMIT TO CLOS UYDERGROLWD STORAGE 14,`rl S STORING HAzi— DOUS MATERIAL GENERAL INSTRUCMPIS: ( � 1. Submit all information in rapticue. Answer all questions, leaving no blatuls. One copy will be returned to the applicant with comments. ( � 2. Include a detailed site map on a separate sheet of paper,showing the tocation of the ranks(s), piping, streets, adjacent properties (north toward the top of the page),nearby septic tanks,leach$elds,water wells, buildings, underground public unary lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utiiiries are not included on the site map, you must state in writing that I;SA Dig will be contacted prior to excavation acriviries. ( ( 3. Complete page 3. 'Application for iJnderground Tank Closure Permit'. It. Complete page 9, 'Authorization to Release AnAlyti=l Data''. This form must be signed and oared by the Ot;i•NER/OPER4TOR of the faqir". a : i. Submit the appropr.'ace fees and comrie:e page n, the*Underground Tank Program Fee worksheet". ( ] 6. Complete all gnestictis on page 10, the Public Hesith Services-Enytitonmencat Health Division (PHS_F1. M) 'Underground Storage Tank Disposition Tracking Record', except chose requiring a signature and dace of tank removal. The tiolcler of the permit Shail ye responsible for ensuring that rhis form is completed and returned to PHS.RHD within 3C days of the rank removal. �7t Submit a 'Site Health & Safcry Plan' as an addendum to this application, to address all potential "l 'hazards for this Specht job site. Refer ro the Site Safery Plan Guidance Document for specifics. ( j 3. If facility is located outside rf the city Urrms, submit a 'BnetII11 Excavation Cercirieace" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building ::ode S'I'D 70-11. ( 1 9. Obtain a 'Grading and Pxmvadon Permit' from the City of Tracy Building Division prier to P14S- EHI3 approval of the closure plan. 10. 7he maximum renew rime for Closure Plans is 15 working days from reuipt of the adequately completed plan. If gross deticiences are identified, an addendum will be required with a 578.00thcur fee and the review will' begin on the late of resubmitral. ( 11. Submit verification of the fire permit from the appropriate fire district at the removal inspeaicu. ! � 1Z dvance ins'oecti n notice of ac lest hos is reouired by P14S-EHD. EH 25 007 (Revised 111lr5'Z) page I J, D,'IYIun or Son IO+7VIn County Heuah C'+rr aeme"