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r ti- PUBLIC HtALT-H SERVICES o oPaU!ev. roc SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer 304 East Weber Avenue, Third Floor • Stockton, CA 95202 F414 209/468-3420 pFRM jSI —Fq�H APPLICATION FOR PERMIT TO CLOSE F5' UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS I. GENERAL INSTRUCTIONS: 1. 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 of the page), nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (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. [� 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". of : Sampling firm shall be an independent third party from the contractor. [� 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the OWNER/OPERATOR of the facility. [] 5. Submit the appropriate feed complete page 11, the ""UUndfrground Storage Tank Program Fee Worksheet". sz - at� U 7, P , 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS- EHD) "Underground Storage Tank Disposition Tracking 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 repurned to PHS-EHD within 30 days of the tank removal. H CY.tj., [.0 er Sf"' -e— / 6-�.Y --rq/yv ct of hum a,4 0&9-t<.✓ (e]' 7. Submit a "Site Health & Safety Plan's 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. If 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. 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD approval of the closure plan. Allo] 10 The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed I Allo plan. If gross deficiencies are identified, an addendum will be required with a $87.00/hour fee and the review will begin on the date of resubmittal. g1lSubmit verification of the fire permit from the appropriate fire district at the removal inspection. Advance inspection notice of at least 48 hours is required by PHS-EHD. Submit Contingency Plan for over-excavation at time of UST removal (if planning to over-excavate). See "III. SITE MITIGATION" on Page 2. EH 23 046 (Revised 09/21/00) Page 1 A Division of San Joaquin County Health Care Services