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PUBLIC HEALTH SERVICES 1aRA�IN.. <br />SAN JOAQUIN COUNTY r "� <br />ENVIRONMENTAL HEALTH DMSION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton CA 9 202 <br />209/468-3420 �i,�rl/� <br />APPLICATION FOR PERMIT TO CLOSE `S C- (Yf79yC r c/5aCTj <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />I. GENERAL INSTRUCTIONS: <br />[� 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br />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), and <br />distance of piping from tank to dispensers. If underground utilities are not included on the site map, you <br />1 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 parry from the contractor. tvl u S F pr4- Jt� <br />[(]� 4. Complete page 9, ".Authorization to Release". This form must be signed and dated by the <br />OWNER/OPERATOR of the facility. <br />_ N2ec�s �t(lc��i.uh�yt� i�isD�"��u, <br />5 <br />[ j . Submit the appropriate fees and complete gage 11�,7pthe 'Un and Storage Tank P-roP� Fge <br />Worksheet". �cs/�utP-�L bccG{� ,T 0lpti Gt r t �v <br />`yk � —72o t.F z /tC.{.- U': a L, �(/ a Gf G' -C_.. VVU <br />[ ] 6., C pdht Tete all questions on page 10, the Public He Service-EEnvirommental 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 fl is <br />completed and returned to PHS-EHD atm 30 days of the tank removal. <br />ct,� u , C? -k cZtitced 0-7- ,fi� All h <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 />CtY 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 rhe incorporated City Building Departments, <br />pursuant to the Utriform Building Code STD 70-11. <br />9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br />, <br />(� J , EHD approval of the closure plan. <br />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 S78.00/hour <br />fee and the review will begin on the date of resubmittal. <br />e112Submit 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. <br />EH 23 046 (Revised 7/11/98) Page 1 <br />A Division of San Joaquin Counm Hahn Cart S<cviccs <br />