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PUBLIC HEALTH SERVICES , A ly SAN IOAQUM COUNTY 4-�' ENVIRONMENTAL HEALTH DMSION w- Karen Furst, M.D., I.P.H., Health Officer - �. 304 East Weber Avenue, Third Floor • Scockron, CA 95202 209/468-3420 7S0 -4 . radezAPPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS I. GENERAL INSTRUCTIONS: Submit all information in triplicate. Answer all questions, f ��ing no blanks. One c py will be returned to the applicant with comments. 4Q�� e�:d p any ( ] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, / streets, adjacem properties (north toward the top of the page), nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included an the site map, you must state in writing that USA Dig will be contacted prior to excavation activities [ ] 3. Complete page 3, 'Application for Underground Storage TankClosure Permit"- am t". Note: Spling -firm-firmshall be za indmendent 'hrd narry from the mnnartnr Ns EfprT�� - C14 Complete page 9, *Authorization to Release'. This form most be signed and dazed by the OWNIMOPERATOR of the facility. HAVE pW)ie r S%Qyl 9 �us*u3Q94'ot�� [ 1 S. Submit the appropriate fees and complete page 11, the 'Underground Sto a Tank Program Fee / Worksheet". -rkt. --t.5 ( ) 6. Complete all questions on page 10. the Public Health Services-Environmental Health Division (PHS- EHD) "Underground Storage Tank Disposition Tracking Record", except those requiting a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD within 30 days of the tank removal. [-f"" 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential / hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics_ (�} 8. If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-11. 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- EHD approval of the closure plan. [0. The maximum review time for Closure Plans is IS working days from receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a S78.00/hour fee and the review will begirt on the date of resubtrunal. [] I1. Submit verification of the [ire permit from the appropriate ,vire district at the removal inspection. ] I2 Advance inspection notice of at least 48 hours is required by PHS-EHD EH '-3 046 (Revised 10/19/98) Page I �� +� A Division of San Joaquin Caunw r?elm C se Semen