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•PUBLICHEALTH SERVICES ,ori <br /> SAN JOAQUINCOI-'NTY <br /> JOGI KHANNA M.O.M P li l . <br /> Heiith 0ffiter <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95'_01 a <br /> (209) 468-3+00 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING TIA7 tRDOUS NLATERIALS <br /> GENERAL INSTRUCTIONS: <br /> ( ( L Submit all information in triplicate. One copy is returned to the applicant with comments. <br /> [ ] 2. Include a detailed site map, on a separate sheet of paper, showing tank location and type, piping, <br /> streets and adjacent properties (north toward the top of the page),location of the nearby septic tanks, <br /> leachfields,wells,buildings,underground public utility lines (including water,sanitary sewer and storm <br /> sewer), and distance of piping from tank to dispensers. <br /> [ ] 3. Complete page 3, 'Application for Underground Tank Closure Permit% <br /> [ ] 4. Complete page 9, 'Authorization to Release Analytical Data'. <br /> [ ] <br /> S. Submit the appropriate fees and complete page 11,the'Undergmund Tank Program Fee Worksheet'. <br /> [ ] 6. Describe on pages 4&5 the decontamination techniques if applicable,material(s) utilized for rinsate, <br /> transportation and/or storage of hazardous waste generated on site, and specify the responsible <br /> parry(les) who will be disposing of waste generated on site. <br /> [ ] 7. Describe on page 5 the method for purging and/or inerting tank(s) and piping. <br /> ( ] 8. Describe on page 5 in detail how soil and/or water samples beneath the tank(s) and piping will be <br /> obtained. <br /> [ ] 9. Complete the pertinent section of page 10,the Public Health Services-Environmental Health Division <br /> (PHS-EHD) 'Underground Tank Disposition Tracking Record'. The holder of the permit shall be <br /> responsible for ensuring that this form is completed and returned to PHS-EHD. <br /> [ ] 10. 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 Site Safety Plan Guidance Document for specifics. <br /> ( ] 11. Submit a 'Compaction Report' as required by the County of San Joaquin Building Department and <br /> it's incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1. <br /> [ ] 12. Obtain a 'Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> [ ] 13. 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 S53.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> [ ] 14. Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal <br /> inspection). <br /> ( ( 15. Advance inspection notice of at least 48 hours is required by Public Health Services. <br /> Page 1 <br /> , <br /> A Dn .e N San lmgwn C,—. Holm(''rc S Mc- <br />