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PUBLIC HEALTH SERVICES <br /> �Ap 1ry. <br /> o ' F <br /> SANj0AQ01N COUNTY t <br /> jOGI KHANNA M U,MY II. � �� <br /> Health 0f(iur � <br /> P.O. Boz 2009 • (1601 East Huckon Avenue) • Stockton, California 5201 �l P64P <br /> (209) 468-3400 AF R, 2 0 1934 <br /> APPLICATION FOR PERMIT TO CLOSE, MI LNTAi.HEALTH <br /> UNDERGROUND STORAGE TANKS STORING RAZARDOUS Mh� SERVICES <br /> GENERAL INSTRUCTIONS: <br /> ( j 1. Submit all Information In triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to 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, <br /> streets, adjacent properties (north toward the top of the page), nearby septic lanks, leachfields,water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and slorm sewer), <br /> and distance of piping from lank to dispensers. If 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 /> ( j 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> ( j 4. Complete page 9, "Authorization to Release Analytical Data This form must be signed and dated <br /> by the OWNER/OPERATOR of the facility. <br /> ( ( 5. Submit the appropriate fees and complete page 11, the"Underground Tank Program Fee Worksheet'. <br /> ( ( 6. Complete all questions on page 10, the Public Health Services-Environmental Ilealth Division <br /> (PHS-EFID) "Underground Storage Tank Disposition Trucking Record", except those requiring a <br /> signature and date of lank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PIIS-EFID 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 "Backfiil Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the Incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-I1. <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 /> ( j 10. 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 requited with a S78.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> I <br /> ( j 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 PI IS-EHD. <br /> I <br /> Elf 23 007 (Revised I1/1/92) Page 1 <br /> . <br /> A DlNalm d San f�quCwn'r lk jth Carc 5cMC. C� <br />