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10/17/2000 09:00 2094683433 FIFTH FLOOR PAGE 01 <br /> PUBLICH'CALTH SERVICES <br /> SAN JOAQULN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION ' *! <br /> Kasen Furst, M.D., M.P-i_, Health Officer <br /> 304 East Weber Avertuet, Third Floor • Stocktor�, CA. 95202 <br /> 209/468-3420 r x ly 68 - 3g3 Is <br /> ARMCAUO_N FOR PERMIT TO CLO E <br /> UNDERG1rtb 'D STORAGE TAYKS STORING HAZARRM S MATERLU R <br /> I. GENEktAL INSTRUCTIONS: <br /> f] 1 Submit all information in triplicate Answer all questiow, leaving no blanks. One copy will be returned <br /> to the applicant with corzutzesita. < <br /> [] 2 Include a detailed site map on a separate sheet of pqw, showing the locauou of the Wft(s), piping. <br /> streets, ad}acew properties (north toward the top of the page), nearby septic tanks, leachfields, water <br /> wets, buildings, underground public utility lines (b=linding wz , sm ury seweui " storm sewer), &ilei <br /> distance of pJpirig from time to dispensers. If undtrground ua'l isles are not iiicluded on the sate map, you <br /> must state in writitag that USA Dig x111 be contacted prior to excavation acuvittes <br /> [3 3 Complete page 3. "Application for Undargxaraad Storage Tank Closure Permit". Q: Sampling <br /> film shall be as ladepgLdm third 2M from the contractor <br /> [] 4 Complete page 9. "Authorization to Release" This form must be signed and dated by the <br /> OWINMOPERATOR of the facility. <br /> 5.. Submit the appropriate fres and complete page 11, the "Ueda roamd Storage Tattle Program Fee <br /> + Workshe t". <br /> Complexe all questions an page 101 the public Health Servlcas-Eavirom=mal Heatth Division (PRS. <br /> EHD) "Underground Storage Tank Disposition Tracking Reoard", except those requIring a signature <br /> an& date of tank removal The bolder of the permit stall be responsible for t:n ming that this farm is <br /> ta <br /> completedurn <br /> and returned to PHS-FHD�within 30 days of rite me rrmovaI <br /> {3 7. Subrmt a 1 Site Health &Safety plan} as an addendum to this application, to address all potential hazards <br /> for this specifie job site. Aefer to lite Site Safety Plan Guidance Documertt for specifics <br /> [] $. If facility is located outside of the c>y lwwts. submit R "Hackflll liw avationl CertiffeWe" as mqu hod by <br /> the County of San roagwn SwingI apartment and the incorporawd City Buildmg Depaiu= � <br /> li •p <br /> to e Ylaiform Buil" STD I 11. <br /> 11 9. Obtain a "Gradiric and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD <br /> approval of the closure plum <br /> [ ] 10 The maximum review time for Closure Plana is 15 working days from receipt of the adequately completed <br /> plan If gross deficlenciu are identified., an addendtiz:4 will be requhvd with a U7.001hour tee and the <br /> review will begin on rhe dare of m=iEcLittaZ <br /> [ <br /> 11 Submit venfication of the fire permitlfrom the appropriate fire district at the removal inspection <br /> C ] 12 Advance inspection sioace of at ZLbours is mired by PH&EHD. <br /> [3 13. Submit Contingency Plan for over avatloti at time of UST removal(if pla—inn to over-excavasc) <br /> See "In. SITE MITIGATION'" on page 2. <br /> 03 046 (Revised 09121100) Paige 1 Post4t°Fax Nota 7671 CWU .06 <br /> p.gas� <br /> A Dnl9ion of Son Jonqu:n Cal <br /> Ca/Dap' \14.6 eta 4 a as 6 <br /> MbD <br /> Plgf10• 4'?Wnf Y <br /> fax 0 �1f <br />