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ENVIRONMENTAL HEALTH DEPARTMENT <br /> UVI <br /> Donna K. Heron,R.E.H.S. SAN JOAQUIN COUNTY Unit Program Coordinators <br /> Director 600 East Main Street Carl Borgman,R.E.H.S. <br /> Stockton, California 95202 Mike Huggins, R.E.H.S.,R.D.I. <br /> Laurie A.Cot ulla,R.E.H.S. Telephone: (209)469-3420 Margaret Lagorio, R.E.H.S. <br /> Assistant Director Robert-,McCiellon,R.E.H.S. <br /> Fax: (209)468-3433 JeffZarrueseo,R.E.H.S. <br /> APPLICATION FOR PERMIT TO 'CLOSE <br /> UNDERGROUND STORAGE TANK&STORING HAZARDOUS <br /> I. GENERAL INSTRUCTIONS: <br /> I. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be:returned to the <br /> 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,buildings,underground <br /> public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If <br /> underground utilities are not included on the site map, you must state in writing that USA Dig will be contacted prior to <br /> excavation activities. <br /> 3- Complete pages 3-6, "Application for Underground Storage Tank Closure Permit". of :Sampling firm shall <br /> be an independent thirdparty from the contractor. <br /> 4. Complete page 9, "Authorization to Releax his <br /> .-d �1 form must be signed and dated* by the <br /> OWNER/OPERATOR of the facility. <br /> 5. Submit a"Service Request"form with the appro <br /> t completed UPC forms for Facility and Tanks <br /> (formerly State A&B forms)and complete the"Under kProgram Fee Worksheet". <br /> 6. Complete all questions on page 10, the Environ (EHD) "Underground Storage Tank <br /> Disposition Tracking Record",excWt those req iringy a si <br /> removal. The holder of the permit shall <br /> be responsible for ensuring that this form is completed and "30 days of the tank removal. <br /> 7. Stibmit a"Site Health&Safety Plan" as an ad to address all potential hazards for this <br /> ..... ...... <br /> specific job site. Refer to the.Site Safety Plan Guidance D <br /> .................. <br /> ........................ <br /> 8. If facility is located outside of the city limits, submit -!!`i -re <br /> quired by the <br /> County of San Joaquin Building Department and the.in City.Ru <br /> flo Depar4nentp, pursuant•to the Uniform <br /> Building Code STD 70-11. <br /> 91 Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of <br /> the closure plan. <br /> 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If <br /> gross deficiencies are identified, an addendum will be required with a$105.00/hour fee and the review will begin on the <br /> 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 07/31/08) <br />