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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DMSION < <br /> Karen Furst, M.D., M.P.H., Health Officer t — <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> (33 tt N• ff cam <br /> APPLICATION FOR PERMrr TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> / I. GENERAL INSTRUCTIONS: <br /> [I}' 1. Submit ail information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. <br /> ED] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br /> ED <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), and <br /> distance of piping from tank to dispensers. If underground utilities are not included on the site map, you <br /> must state in writing that USA Dig will be contacted prior to excavation activities. <br /> [ ] 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". Note: Sampling <br /> firm shall be an independent third party from the contractor. <br /> [� 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility- <br /> 5 <br /> lfacility. <br /> 54uyd✓ar <br /> fees and complete page 11, the 'Underground St97ge Tank Program Fee <br /> Worksheet Nom{S '4D Pte- bae,� � Q- <br /> [� 6. Complete all questions on page 11_0, the Public Health Services-Environmental Health Division (PHS- <br /> EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br /> and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is <br /> / completed and returned to PHS-EHD within 30 days of the tank removal. <br /> [3y <br /> Y. 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 /> [y 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by <br /> 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 plan. <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 578.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> [ ] <br /> 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> ( ] i^_. Advance inspection notice of at least 48 hours is required by PHS-EHD <br /> EH '--3046 (Revised 10/19/98) Page 1 <br /> A Division of San Joaquin County Health Care Sctvices <br />