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PUBLIC HEALTH SERVICES <br /> SAN ;OAQUIIN COUNT`. <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> Karen Fuzst, M.D., M.P.H.. Health Of:xc2r r �' <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 09/468-3420 <br /> dz,vr*r s rr0.FOR PFRb!!T TO CLOSE <br /> L1iiDER rROL,I STORAGETANA" TORriG HAZARDOLrS NLATE RIALS <br /> t, GENERAL INSTRUCi'TO`iS: <br /> !. Submit a!1 iaforradon in triplicate. Answer all questions, leaving no blanks. One copy 'rill be returned <br /> to the applicant with==-nems. <br /> Include a detailed site map on a seoart- sheer of paps. showing the location of the taaks(s;, Piping, <br /> strew, adjacent prbpe:des (north toward the top of tde page), nearby septic tanks, leachrleltL, water <br /> wells, buildings, tmdergrouad public utility: lines ineiudiag water, sanitary sewer and stone sewer), and <br /> distance of piping from tank to dispensers. if urdergrot_.d utilities are not_nciuded on the site map. you <br /> must state :n writing that USA hig wdl be contac::d prier to eaeavatier,acts;nes, <br /> 1 _. Complete page 3, .application for Undergrotmd Storage Taak Closure Permit". ;FFt: line <br /> firm shall be an indenerdent chird bars fro-n rhecantrac:s. <br /> i 1 4. Complex page 5, "Authorization to Release-. nis form must be signed and dated L— the <br /> OWrNER/OPERATOR of the facility <br /> _ 7 :. Submit the ap;ropriam fees and coariac page 11, the 'Underground Storage Tank Program Fee <br /> Work..ibect <br /> Complex all questions_ or. page l0, the Fsbtic Health Services-Environmental Health Division (PHS- <br /> EHD) "Underground Storage Tank Disposition Tracidne, Record", ezccpt Grose requiring a signature <br /> and dace of a i< removal. T.".e hoiden at jrs get3.it sic+!; be resporsi�le for ensuring that this fern is <br /> completed and returned:o PHS-EBD within 30 days of the tank removal. <br /> tentia: <br /> hti mit a "She Health & Safety Plan" as an addendum to this apolicaticc, to address all po <br /> hazards for :his speci.`.c job site. Rafe:to the Site 5afety clan Guidance Document for apdci`cs. <br /> ( j S. If facility is located ou-side of the city limsu <br /> its, bmit a'Backfin Eteavatian Certineate" as required b;' <br /> he County of San icaquin Bcildin; 3epars ent ars the incorporated City Building Depermlcns. <br /> p,isuart to rhe Unlrerm Buitdirc Code STD 70-1:. <br /> [ 9 <br /> Obtain a "Grading and Excavation Permit" -Oro the City os Tracy Building Division prier to PHS- <br /> HD approval of the ciesure plant. <br /> 133emaximum review :h- for Closure plans is 1d working days from rtr_-ipt of the adequately: <br /> completed pl r. If gross def cietcies a e identified, an addenc,.am wil! be requir_d w rh a $78.00,ha c <br /> fee and the review will begin on the dare of tesuhmiral. <br /> Submit vetfcaticn of the fire pert fro=the appropriate the district at the rcabV21 irs;zc^on. <br /> I I 1? advance iasle .cion recce of at leas ' hpurs 1s r�uired by PW 5-EriD <br /> j 13. <br /> Sabah ContirgeneY Plan for over-zacsa o at time o,'UST removal (if planning to ovx-excavate). <br /> See "III, SITP.yIITIGATION" cr.Pa_e' <br /> EH 23 046 �Ravised 0&'13:99) Page 1 <br /> A pi4isien d.5a^.ieagtdn Cou.^.:r Heai:h Cao Se=.cess <br />