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,SAN .IOAQUIN COUNTY <br />I Y <br />I;NVtltt)NMI;N"I'AL ilisAL'1111 DIVISION <br />I;rllcsl M. huJhmolo, NLD., M.l'.Il., Acting Ilenl(II Officer <br />445 N. Still .Ionquia Street e 1% 1). Ilos 388 a Stoekinn, CA 95201-0388 <br />2119/468-3420 <br />�clraaa <br />I <br />(IF,NIlRAL INSTRUC11ONS: <br />(( 1. Sahndl nil Information in ulpllcnle. Answer fill geestions, leaving no blanks. one copy will be <br />retan,cd In the nppooltil wflll comments. <br />), IIIIIIIIIIe a Metalled she rilnil on a AcpwralC 511ee1 <br />of pallcf,,1Ilowing the location of the IRnks(s), piping, <br />s1tee19, adjacent hlollertles (Ilerlln Iownid the NII, of the page), neRrhy seplic tanks. Ieachrields, water <br />wells, balldings, nrltlelgimilnd public Illiliry ones (Inclaturlg wafer, SRnllsry sewer slid slotm sewer), <br />will d/srnnce of piping bowl rank to dispensers. If andelgiolmd anlllies,lod not Inchlded on the site <br />al"ll yoe Dorsi sante In willing that USA �g will be conlncled prior W excavation acllviUes. <br />/ <br />3. Cuugdcic pnge 3, "Applicnllon for lhitlelp und'1'nnk Clostlre I'ermil". <br />Ct llipicle Pnge, 9, 'MdRo I .orlon to Itctense Anniyncnl Untn". 'fids form most be signed and doled <br />by the UIWNEIVO1TnA'I OR of the facility. <br />i <br />S. Subodl the fipplopofile (ccs tind complete pwge 11, the "Unitergroond Talk Program Fee Worksheet". <br />(� r. Conglicte till ip,c%lhlrls on page Ill, he Public licallh SetvIces-I3ovironmental flealth Division <br />(PIIS-fi111J) "llndergrmmd Storage 'I'mlk Dlsposlllon '1'tacking Itecerd", except those tequiring a <br />stgufitnre and date of tank renlovwl. 'lhc holder of the petndt shall be responsible for enseting that <br />this lotm is completed find lclorned to PI IS-t:J ID within 30 days of the lank temoval. <br />1 7. Submit it 'She Ilenith A Sntely 1'Inn' as nil athletlll11I11 In 1111,1 application, to address all potential <br />htinnds for this specl(ic lot, site. Itefer to the Site Safely plan (fuldonce Document for specifics. <br />8. If facility Is located outside of file city Iln111s, 5111)11111 a "Ilncklill rXeriva(lon Certificate' as tequlre <br />by file County of San lotigoin Vullding Depwrtmenl and the Incorporated City Building Depart , <br />Jiutsunnl In the Uniform oullding code S'ID 711-11. <br />i 9. Obtnhl a "I.rnding mod rxcnvntion 1'erndr' from UIe city of Tracy Dodding Division pflur to PDS - <br />CI ID approvnl of IIIc closule Jilin. <br />(i 10. 'l lie nmshtl11nl review tittle lot Closure Plmis 15 15 working days from receipt of the adequately <br />etlltipieted Illnn. It glass deflulellcles me Ilteololled, nn nddendmn will be required with a S78.00/1109t <br />fee and the tevlcw will begin on elle dole of rMlIbnllUnl. <br />11. Subn111 verification of file fire permit front the oppropriale Ore district at the removal Inspection. <br />I1. Advance hos Ici ctiun outice of of lens( 48 Imurs Is Icuuhcd by P11S-L11D, <br />lilt 231411 (Revised II/IN2) Inge 1 <br />A 111 -bion of Son Jn"galn Cnnnq Ile'llf, Cue Servlrex <br />