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UBI4C EAL 1 H STZWCES ar SAN tOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION W. Ernest M. Fujimoto, M.D., I.P.H., Acting Health Officer c,epP 445 N. San Joaquin Street • P. O. Box 388 • Stockton. CA 95201-0388 209/468-3420 / APPLICATION FOR PERIM7 TO LOS A UNDERGROUND STORAGE TAN-KS STORING gAZAxllOUS MATERIALS �v GENERAL INSTRUCTIONS: (� 1. Submit all information in triplicate. Answer all questions, leaving no blan . One copy will be returned to the applicant with comments. ( ] 2. Include a detailed site map on a separate sheet of paper,showing the logia.otanks I n of the anks(ldspriping streets,adjacent properties (north toward the top of the page), nearbyseptic llllll�� 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 on the site map, you must state in writing that USA Dig will be contacted prior to excavation activities. 3. Complete page 3, 'Application for Under aground Tank Closure Permit". ( r 4. Complete page 9, 'Authorization to Release Analytical Data'. This form must be signed and dated by the OWNER/OPERATOR of the facility. (� 5. Submit the appropriate fees and complete page 11,the *Underground Tank Program Fee Work sheee. ( j 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS-EHD) 'Underground Storage Tank Disposition Tracking Record', ecceot those requiring 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. 7. Submit a 'Site Health & Safety Pian' 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. ( j �3. R facility is located outside of the city limits, submit a Backfill Excavntion 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 Ciry of Tracy Building Division prior to PHS- I"I�(V EHD approval of the closure plan. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gloss deficiencies are identified.an addendum will be required with a S i8.00/hour fee and the review will begin an the data of resubmittal. Submit verification of the are permit from the appropriate fire district at the removal inspection. ( � 12. Advance insnection notice of at least 43 hours is required by PHS-EHD. EH 23 007 (Revised 11/1,42) Page 1 A Division of San Joaquin Coumr Hearth CGre Se"Wes y