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s ENVIRO*IENTAL HEALTHO)EPARTNIENT <br /> PaLf11Y SAN JOAQUIN COUNTY <br /> yo. .cap Unit Program Coordinators <br /> 2;' y Donna K.Heran,R.E.H.S. 304 East Weber Avenue, Third Floor Carl Borgman,R.E.H.S. <br /> Director <br /> `�: • °j Stockton, California 95202 Mike Huggins,R.E.H.S.,R.D.I. <br /> Laurie A.Cotulla,R.E.H.S. Telephone: (209)468-3420 <br /> Kasey Foley,R.E.H.S. <br /> Cq ii`P Assistant Director Fax: (209) 464-0138 Margaret o,R.E.H.S. <br /> �rF©� Robert McCClellaen an,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. Answer all questions,leaving no blanks. One copy will be returned to <br /> 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,streets, <br /> adjacent properties (north toward the top of the page), nearby septic tanks, 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'. of : Sampling firm <br /> shall be an inde endent third pa from the contractor. <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 a "Service Request" form with the appropriate fees, submit completed UPC forms for Facility and <br /> Tanks (formerly State A & B forms) and complete page 11, the "Underground Storage Tank Program <br /> Fee Worksheet". <br /> [] 6. Complete all questions on page 10,the Environmental Health Department(EHD) "Underground Storage <br /> Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The <br /> holder of the permit shall be responsible for ensuring that this form is completed and returned to EHD <br /> within 30 days of the tank removal. <br /> [} 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards <br /> 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 by <br /> the County of San Joaquin Building Department and the incorporated City Building Departments,pursuant <br /> to the Uniform Building Code STD 70-11. <br /> [] 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD <br /> approval of the closure plan. <br /> [] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed <br /> plan. If gross deficiencies are identified, an addendum will be required with a S95.00ihour fee and the <br /> review will begin on the date of resubmittal. <br /> [] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [] 12. Advance inspection notice of at least 48 hours is required by EHD. <br /> [] 13. Submit Contingency Plan for over-excavation at time of UST removal(if planning to over-excavate). <br /> See"III. SITE MITIGATION'on Page 2. <br /> EH 23 046 (Revised 7128106) Page 1 <br />