Laserfiche WebLink
10/17/2000 09: 00 209468 3 FIFTH FLOOR PAGE 01 <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQLTIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer (t• 5`}" <br /> 304 East Weber Avenue, Third Floor • Stockton, CA, 95202 l z <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGIR STORAGE TANKS STONING HAZARDOUS MATRRiAi R <br /> I. GENERAL INSTRUCTIONS: <br /> (] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. <br /> [] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanlcs(s), piping, <br /> streets, adjacent properties (north toward the top of the page), nearby septic tattles, leachfields, water <br /> wells, buildings, underground public tuility lines (incluciing water, sanitary seww and storm sewer), and <br /> distance of piping from rank to dispensers. If underground utilities art not included on the site map, you <br /> must state in writing that USA Dig will be contacted prior to excavation activities. <br /> [) 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". of : Sampling <br /> firm shall be an lrtdc2Wem third party from the contractor. <br /> [7 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> ( ] 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> [] 6. Complete all questions on page 101 the Public Health Services-Eavironmemal Health Division (PHS. <br /> EHD) "Underground Storage Tanla Disposition Tracking Record", except those requiring a signature <br /> and date of tank removal. the bolder of the permit shall be responsible for ensuring that this form is <br /> completed and returned to PHS-EHi�w•fthin 30 days of the tank rcmoval. <br /> (] 7. Submit a "Site Health a Safety Plan" as an addendum to this application,.to address all potential hazards <br /> 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 "Backfill Excavation Certificate" as required by <br /> the County of San Joaquin Building Iteepartment and the incorporated City Building Departments,pursuant <br /> W the Uniform Building Code STD 2I 11. <br /> [l 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD <br /> approval of the closure plan. <br /> [ ] 10. The maximum review dine for C1owFe Plans is 15 working days from receipt of the adequately completed <br /> plan. if gross deftcienewe are identified, an addenGum will be required with a S$ -001horur fee and the <br /> review will begin on the date of resubmittal. <br /> [ ] 11. Submit verification of the fire permit . <br /> lfrorn the appropriate fire district at the removal inspection <br /> i <br /> [ ] 12. Advance inspection notice of at least!38 hours is required by PHS-EHD. <br /> [] 13. Submit Contingency Plan for over-exI avation at time of LIST removal(If pla>ming to over-excavate). <br /> See "III. SITE MITIGATION"on Page 2. <br /> EH 23 046 (Revised 09/21/00) Page 1 Post-W Fax Note 7671 Data 10 A-4 paw► <br /> A Division or S.n ionquin Col To CV mem <br /> i <br /> CaJDept. Co. <br /> ' PPolw♦ rlronf N <br /> FaxA�� <br />