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U2/11/ZUU4 l4:uo ran aiuoaoioii . ._ ^ ' <br /> FEB-02=04 17:27 FROM-KLEEMAN ROMEO 916-939-1169 T-T46 P.05/17 F-539 <br /> PUBLIC HEALTH SERVICES �. . <br /> SAN JOAQUIN COUNTY a <br /> ENVIRONMENTAL.HEA1-TH DMSION r " <br /> Karen Furrc,M.D., M.P.H., Health Officer i <br /> 304 East Weber Avenue,Third Floor t Stockton.CA 95202 <br /> 209/468-3420 <br /> APPLICATION FOR PERW T TO CLOSE <br /> UNDERGROUND STORAGE TANKS 5 O ,'G HAZARD US MATERIALS <br /> 1. GENERAL INSTRUCTIONS: <br /> Subrnir all information in triplicate. Answer all questions,leaving no blanks. One copy will be returned to <br /> The applicant with comments. <br /> Include a detailed site map on a separate shoot Of paper,shooing the location of the tatllra(s),piping,streets, <br /> .adjaccnf properties_(nordt.toward the Top of the page), nearby septic tank$, leachGelds, water wells, <br /> buildings,underground Public utility litres(including water,sanitary sayer and storm sewer), and distance <br /> of piping from rank to dispensers. If underground utilities are not included on Ore site map,you must am?-- <br /> in <br /> mtein wrung that USA Dig will be oontactcd prior to mtcavation activities. <br /> [) 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". of :Sannoline firm <br /> thou be an independent third nam foul The 5pntractor. <br /> [] 4. Complete page 9, "Authorixagon to Release". This form must be signed and dated by the <br /> OWNERfOPERATOR of the facil(ry. <br /> [] 5. Submit the appropriate fees and complete page Il, the 'Underground Storage Tank Progmen Fee <br /> Norloi-heei". <br /> [] 6. Complete all questions on page 10,the Public Health Services-Environmental Healdi Division(PHS-EHD) <br /> "Underground Storage Tank Disposition Tracking Record",except those requiring a signature and date <br /> of tide removal. The holder of the permit shall be responsible for ensuring that this form is completed and <br /> resumed to PHS-EHD within 30 days of the rank removal. <br /> (] 7. Submit a "Site Health&Safety Plan"as an addendum to this application,to address all potential hazard, <br /> for chis specific job site. Refer To the Site Safety Plan Guidance Document for pacifies. <br /> [] 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 incorporarad City Building Departments, pursuant <br /> to the Uniform Building Code STD 70.11. <br /> ( ] 9. Obtain a "Grading and Excavation permit" from The City of Tracy Budding Division prior to AHS-EHD <br /> approval of the closure plan. <br /> (] 10 The maximum review time fbr Closure Plans is 15 Working days from receipt of the adequately completed <br /> plan. If gross deficiencies are ideatified, an addendum will be required with a S99,00/hour fee and the <br /> review%Hill begin on the date of resubminal. <br /> [] <br /> I]- Suhnur verification of the ire permit from the appropriate fire district at the removal inspection. <br /> (] 12. Advance inspection notice of at least 49 hours is required by PHS EHD <br /> [] 13. Submit Contingency Pian for over-excavation at time of UST removal(if planning To over-cxeavarc). <br /> See"III. SITE MITIGATION"on Page 2. <br /> EH 23046 (Revi5ed&/1/01) Pagel <br /> A Di.•itian of San Joaquin CoenrY Ha kh Gam Scm;e <br /> RECEIVED FEB-11-04 15:09 FROM-9168581011 TO-KLEEMAN ROEBBELEN PAGE 03 <br />