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re <br /> PUBLIC HEALTH SERV ICES <br /> SAN JOAQUIN COUNTY ?, <br /> b: < <br /> JOGI KHANNA M D,M P H <br /> Health Officer <br /> • • Stockton, California 95201 C�[ip oit�`�' <br /> P.O. Box 2l')09 (1601 Ea_a Hazelton Avenue) <br /> (209) 468-3400 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> (� 1. Submit all Information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> // <br /> l)Include a detailed site map on a separate sheet ofpaper,showing the location of the tanks(s), piping, <br /> streets,adjacent properties (north toward the top of the page),nearby septic tanks,leachfields,water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br /> and distance of piping from tank to dispense&lf underground utilities are not included on the site <br /> map,you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> F14. Complete page 3, "Application for Underground Tank Closure Permit'. j3ezr- -Fee. �' 61t� 117 <br /> Complete page 9, "Authorization to Release An lyti1 Data". This form must s ed and dated� b\ y the OWIY�PERA ORR of the facility. /VeaGlS O be-c5%! 1®" } <br /> S16. Y wTJ See J 2c rl�- <br /> Submit thea ropriate fees and corn le page 13,the"Undergro nd Tank Program Fee orksheet". <br /> iia C K+�ee ��doer a 7..m & LL-t-"Complete all questions on page 10, the Public Health ervices-Environmental Health Division <br /> (PHS-E.HD) "Underground Storage Tank Disposition Tracking Record', except those requiring a <br /> signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PHS-EHD 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 <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 /> -Z-� by the County of San Joaquin Building Department and the incorporated Cfty Buildin Dgpartments, <br /> pursuant to the Uniform Building Code STD 70-11. -�•ce(riyu--U w/�1„h-� 3�G£ <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 /> [ 110. 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 a $78.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> [ ] <br /> 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> J 12.12. , Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> -3-/()- q Y 1-Z <br /> EH 23 007 (Revised 11/1/92) Page 1 <br /> f}m bum ice -�o Ire <br /> A Dhialon of Son Joaquin County Health Care Se cm (�� <br />