Laserfiche WebLink
' ENVIRONMENTAL HEALTH DEPARTMENT <br /> OSAN JOAQUIN COUNTY <br /> P C <br /> � ^"'"� �� Urrrt Supen�rsors <br /> Donna K Heran,R E H 5 <br /> Direclnr 344 East Weber Avenue, Third Floor Mike Huggins,R Carl Bor manS <br /> ,R E II H S, S D [ <br /> • Al Olsen,R E Hs Stockton, California 95202-270$ Douglas W Wilson, R E N S <br /> a�P Program Manager Telephone (209) 468-3420 Margaret Lagono,R E 11 S <br /> FR OLaurie A Cotulla,R E H S <br /> Plagrani Manager Fax (209) 464-4><38 Robert McGlcilon,R E 1E S <br /> Mark Barcellos,R E H S <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> ' I 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 /> to writing that USA Dig will be contacted prior to excavation activities <br /> ' [] 3 Complete page 3, "Application for Underground Storage Tank Closure Pernut" ote Sampling firm <br /> shall be an independent third na=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 tees, 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 /> [] b 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 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 /> [] S 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 /> [] 9 Obtain a "Grading and Excavation Pernut" from the City of Tracy Building Division prior to EHD <br /> ' approval of the closure pian <br /> [) 10 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 $89 00/hour fee and the <br /> ' review will begin on the 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 3/15102) Page 1 <br />