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1ENVIRONMENTAL HEALTH DEPARTMENT <br /> pP�"`" SAN JOAQUIN COUNTY <br /> a Unit Program Coordinators <br /> r:' t Donna K.Heran,R.E.H.S. <br /> 600 East Main Street Carl n, R.E.H.S. <br /> Di <br /> rector Mike Huggins, <br /> R.E.H.S.,R.D.I. <br /> Stockton, California 95202 Margaret Lagorlo,R.E.H.S. <br /> �dPl ca"aa Laurie A.Cotulla,R.E.H.S. Telephone: (209)468-3420 Robert McClellon,R.E.H.S. <br /> 1 Assistant DirectorJeff Canuesco,R.E.H.S.Fax: (209) 468-3433 <br /> Kasey Foley,R.E.H.S. <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS:STORING HAZARDOU&-MATF�RIAb� <br /> ' .r <br /> I. GENERAL INSTRUCTIONS: <br /> 1 [] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the <br /> applicant with comments. <br /> 1 [] 2. Include a detailed site map on a separate sheet of paper, showing the location of thetanks(s), piping, streets, <br /> adjacent properties(north toward the top of the page),nearby septic tanks, leachfrelds,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 /> 1 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 •Samoline firm shall <br /> ' be an independent third party from the contractor. <br /> [] 4. Complete -page 9, "Authorization to Release,,"_- This form must be signed and date& by the <br /> OWNERIOPERATOR of the facility. <br /> C£CtCx <br /> [] 5. Submit a "Service Request"form with the appropriatC submit completed UPC forms for Facility and Tanks <br /> (formerly State A&B fomu)and complete the"Undergro ., mink Program Fee Worksheet". <br /> 1 [] 6. Complete all questions on page 10, the Environmenia� °' t(EHD) "Underground Storage Tank <br /> Disposition Tracking Record",exc t those re uiring a si slateoftank removal. The holder of the permit shall <br /> be responsible for ensuring that this form is completed and _RW within 30 days of the tank removal. <br /> 1 [J 7. Submit a "Site Health&Safety Plan" as an adder lication,to address all potential hazards for this <br /> specific job site. Refer to the Site Safety Plan Guidance D f! <br /> [] 8. If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate!'.as required by the <br /> County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform <br /> Building Code STD 70-11. <br /> ' [] 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of <br /> the closure plan. <br /> 1 [] 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 /> 1 [] 1 L 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 /> 1 [] 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) j <br /> 1 <br />