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PUBLIC HEALTH SERVICES <br /> SA.N)0AQIa.N(I111:11' t: h <br /> -JV-f IQGI I:HA\I\A NI I).Df l'li A <br /> U \ cv <br /> P.O, flux 2009 • (I(;nl East Huchon Arcnuc) • Stock-ton, Cailfnrnla 932111 rfi�vt O <br /> (209) 46M.3400 D Y <br /> AFTLICA ON FOR PERMIT TO CLOSC FEB 1 1199 <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATLIUAI S <br /> GENERAL INSTRUCTIONS: ENVIRONMENTAL HEALTH <br /> I J <br /> I. Submit all Information In triplicate. One copy Is returned to the applicant with `A)qT V(FT/SERVICE <br /> I J 2. Include a detailed site map, on a separate sheet of paper, showing lank 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 /> J 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> J j 4. Complete page 9, 'Authorization to Release Analytical Data'. <br /> J 5. Submit the appropriute fees and complete page 11,the'Underground Tank Program Fee Worksheet', <br /> J G. Describe on pages 4&5 the decontamination techniques if applicable,materfal(s) utilized for rinsate, <br /> transportation and/or storage of hazardous waste generated on site, and specify the responsible <br /> party(les) who will be disposing of waste generated on site. <br /> � ) 7. Describe on page 5 the method for purging and/or Inertial; tank(s) and piping. <br /> I J fl. Describe on page 5 in detail how soil and/or water samples beneath the tank(s) and piping will be <br /> obtained. <br /> J e. Complete the pertinent section of page 10,the Public Health Services-Environmental Health Division <br /> (PHS-EHD) "Underground Tank Disposition Trucking Record'. The holder of the permit shall be <br /> responsible for ensuring that this form Is completed and returned to PHS-EHD. <br /> I 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 /> J 1t. Submit a 'Compaction Report" as required by the County of Snn Joaquin Building Department and <br /> It's Incorporated City Building Departments, pursuant to the Uniform Building Code STD 70.1. <br /> J 12. Obtain a "Grading and Excavation Permit* from the City of Tracy Building Division prior to PI IS• <br /> EHD approval of the closure plan. <br /> J 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 if S53.W/houf <br /> fee and the review will begin on the date of resubmittal. <br /> J J 14. Submit verification of the fire permit from the appropriate fire district (prior to echeduling removal <br /> inspection). <br /> J 15. Advance Inspection notice or at least 48 hours Is required by Public Health Services <br /> EIJ23-007 (1/10/92) PAGE 1 <br /> A Uivinfun of!xn Jueyuln(:puny Ifrallh f)ur i,•n$o �� <br />