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r.� <br />ENVIROGMENTAL HEALTIWEPARTMENT <br />Donna R. Heraa, SAN JOAQUIN COUNTY <br />R. R . H. s . 304 East Weber Avenue, Third Floor <br />Director Stockton <br />Al Olson, R.E.H.S. ,California 95202 <br />Program Manager Telephone: (209) 468-3420 <br />Laurie A. Cotulla, 209 Fax: R.a.H.s. ( ) 464-0138 <br />Unit Supervisors <br />Carl Borgman, R.E.H.S. <br />Mike Huggins, R.E.H.S., <br />R.D.I. <br />Douglas W. Wilson, <br />R.E.H.S. <br />Margaret Lagorio, <br />R.E.H.S. <br />Robert McClellon, <br />APPLICATION FOR PERMIT TO CLOSE R. E. H. S. <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />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 />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, <br />buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance <br />of piping from tank to dispensers. If underground utilities are not included on the site map, you must state <br />in writing that USA Dig will be contacted prior to excavation activities. <br />3. Complete page 3, "Application for Underground Storage Tank Closure Permit". Pot : Sampling firm <br />shall be an independent third party from the contractor. <br />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 a "Service Request" form with the appropriate fees, submit completed UPC forms for Facility and <br />Tanks (formerly State A & B forms) and complete page 11, the "Underground Storage Tank Program <br />Fee Worksheet". <br />6. Complete all questions on page 10, the Environmental Health Department (EHD) "Underground Storage <br />Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The <br />holder of the permit shall be responsible for ensuring that this form is completed and returned to EHD <br />within 30 days of the tank removal. <br />7. <br />W 8. <br />9. <br />10. <br />] 11. <br />12. <br />11 13 <br />Submit a "Site Health & 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 />If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by <br />the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant <br />to the Uniform Building Code STD 70-11. <br />s�.t-mom <br />Obtain a "Grading and Excavation Permit" from the City of -Tracy, Building Division prior to EHD <br />approval of the closure plan. <br />The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed <br />plan. If gross deficiencies are identified, an addendum will be required with a $93.00/hour fee and the <br />review will begin on the date of resubmittal. <br />Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br />Advance insnection notice of at least 48 hours is required by EHD <br />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 10/16/03) Page 1 <br />