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REMOVAL_1996
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0231337
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REMOVAL_1996
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Last modified
7/1/2021 12:56:59 PM
Creation date
11/5/2018 1:39:33 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
REMOVAL
FileName_PostFix
1996
RECORD_ID
PR0231337
PE
2381
FACILITY_ID
FA0000894
FACILITY_NAME
TOKAY MARKET FOOD & LIQUOR
STREET_NUMBER
2525
Direction
S
STREET_NAME
HUTCHINS
STREET_TYPE
ST
City
LODI
Zip
95240
APN
06024007
CURRENT_STATUS
02
SITE_LOCATION
2525 S HUTCHINS ST 12
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\H\HUTCHINS\2525\PR0231337\REMOVAL 1996.PDF
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EHD - Public
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PUBLIC HEALTH SERVICES <br /> SAIN JOAQUIN COUNTY \ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 %FOR <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UN1DERGROUND STORAGE TANKS STORING HAZARDOUS MAITRiArS <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 ranks, leachfields, water wells, <br /> buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance <br /> of piping from tank to dispensers. If underground utilities are not included on the site map, you must state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> [ ] 3. Complete page 3, "application for Underground Storage Tank Closure Permit". <br /> [ ] 4. Complete page 9, "authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> [ ] 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> [ ] 6. Complete all questions on page 10, the Public Health Services-Environtnental Health Division(PHS-EHD) <br /> "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date <br /> ki <br /> of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed <br /> and returned to PHS-EHD within 30 days of the tank removal. <br /> [ ] i. Submit a "Site Health & Safety Pian" 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 /> [ ] 8. If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-I1. <br /> ( ] 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> [ ] 10. 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 requited with a 578.00/hour fee <br /> and the review will begin on the date of resubminal. <br /> [ ] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [ ] 12. Advance insnecrion notice of at least 48 hours is reauired by PHS-EHD. <br /> EH 23 046 (Revised 7/10/96) Page 1 <br /> f <br /> A Division of Sar.!oacmn Caur.ry Hearth Care Ser:ices <br />
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