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L SERNPUBLIs. � .oG <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor + P. O. Box 388 • Stockton, CA 95201-0388, <br /> 4L1 jid'fi� <br /> 2091468-3420 <br /> PLICATION FOR PERMIT TO CLOSE_ <br /> UNllERGROUND 5TORAGE TANKS STORIIVG HAZARDOUS MATERlAL5 <br /> 1. GENERAL INSTRUCTIONS: <br /> C all questions, leaving no blanks. One copy will be returned <br /> 1. Submit all information in triplicate. Answer <br /> to the applicant with comments. <br /> of <br /> 2. Include a detailed site map on a separate sheet of paper, showing thetic tanks, le the <br /> h tanks($), Pipingswells, <br /> streets, adjacent properties(north toward the top of the page), y F <br /> utility lines(including water, sanitary sewer and storm sewer), anmdistance <br /> s tan 1e <br /> buildings,underground public <br /> of piping from tank to dispensers. If underground utilities are not included on the site map, you <br /> contacted prior to excavation activities. <br /> in writing that USA Dig will be <br /> 3. <br /> Com leteage 3, "Ap lication for Underground Storage Tank Closure Permit". <br /> IV UL J S t<—P <br /> , elease"- This form must be signed and dated by the <br /> 4Complete page 9, "Authorization to R <br /> OWNER/OPERATOR of the facility. <br /> j. Submit the appropriate fees and complete page ll, the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> 6 Complete all questions on page 10, the Public Health Services-Environmental Health Division a S-EHDand ) <br /> "Underground Storage Tank Disposition Tracking Record", except <br /> farpenu ring that thse gis form is completed <br /> of tank removal. The holder of the permsresponsible <br /> and returned to PHS-EHD within 30 days of the tank removal. <br /> lication <br /> �a,f ?. Submit a "Site Health & Safety Plan" <br /> to�e Site Safety Pian Guidanan addendum to this cet Document �, to add specifics- <br /> dress <br /> pec frepotential <br /> hazards for this specific job site. Re <br /> as <br /> equired <br /> { g, If facility is located outside ui � and the�incorporatedoCity Building,Deprartmen s, <br /> by the County of San Joaquin Building <br /> gDepartment <br /> pursuant 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 PHS- <br /> EHD approval of the closure plan. <br /> 10, The maximum review time for Closure <br /> san addendum will bef required wom Pth a$8e00+°Itourtfee <br /> completed plan. if gross deficiencies are denttfed <br /> and the review will begin on the date of resubmittal. <br /> Submit verification of the fere permit from the appropriate fire district at the removal inspection. <br /> [ ] 12. Advance ins ectian notice of at least 48 hours is re uired by PHS-EHD. <br /> EH 23 046 (Revised 9/11/96) Page I <br /> A Division of San Joaquin Cotinty Health Care Services <br />