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0 <br />ENVIRONMENTAL HEALTH DEP <br />Donna K. Heran, R.E.H.S. <br />Director <br />Al Olsen, R.E.H.S. <br />Program Nianager <br />Laurie A. Cotulla, R.E.H.S. <br />program Manager <br />APPLICATION FOR PERMIT TO CLOSE <br />VA7ARTin <br />SAN J OAQUIN C OjJNT <br />304 East Weber Avenue, Third Floor <br />Stockton, California 95202-2708 <br />Telephone: (209) 468-3420 <br />Fax: (209) 464-01.38 <br />_ARTMENT <br />Unit supervisors <br />Carl Borgman, R.E.H.S. <br />Mike Huggins, R.E.H.S., RD - <br />1 -Douglas W. Nilson, R_E.H.S. <br />Margaret Lagorio, R.E.H.S. <br />Robert McClellon, R.E.H.S. <br />Marl: Barcellos, R.E.H.S. <br />I, GENERAL INSTRUCTIONS: <br />1 Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to <br />the applicant with comments. <br />Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), Piping, sweets, <br />2. ae nearby septic tanks, leachfields, water wells, <br />Y <br />adjacent properties (north toward the top of the pa0 sewer and storm sewer), and distance <br />buildings, underground public utility lines (including water, sanitary F You must state <br />of piping from tank to dispensers. If underground utilities are not included on the site map, y <br />in writing that USA Dig will be contacted prior to excavation activities. <br />j 3, Cornplete page 3, "Application <br />for Underground Storage Tank Closure Permit of : Sammi f <br />shall be an Inde endent third a from the contractor. <br />j 4. Complete p <br />age 9, "Authorization to Release". This form must be signed and dated by the <br />OyvrLER/OPERATOR of the facility. <br />for <br />cility and <br />5. Submit a "Service Request" form with the appropriate f ell submit <br />lnderground Stoleted UPC rage Tank aPr Program <br />j Tanks (formerly State A & B forms) and complete p 5 <br />Fee Worksheet". <br />"Underground Storage <br />6. Complete all questions on page 10, the Environmental Health Department (EHD) <br />Tracking Record", except those requiring a signature and date of tank removal. The <br />Tank Dispositionshall be responsible for ensuring that this form is completed and returned to EHD <br />holder of the permit T <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 />as required by <br />] for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics, <br />S. If facility is located outside of the city limits, submit a"BCD oil Excavation ra ed City Builder iDepaertments P �t <br />} the County of San Joaquin Building Department and e rP <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 />I ] approval of the closure plan. completed <br />10 The maximum review time for Closure Plans is 15 working days from receipt of the adequately comp <br />�) gross deficiencies are identified, an addendum will be requited with a $89.00/hour fee and the <br />plan. If gr <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 />j Advance ' ection notice of at least 48 hours is re wired by EHD. <br />12. <br />13, Submit Contingency Plan for Duet -excavation at time of UST removal (if planning to over -excavate). <br />t ] See "III. SITE MITIGATION' on Page 2. <br />EH 23 046 (Revised 3115/02) <br />Page 1 <br />