FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Vi-CrDPUBLIC HEALTH SERopQ...h..� SAN JOAQUIN COUNTYF, ENVIRONMENTAL HEALTH DIVISION Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer F304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 ��/jsd'R�`P 209/468-3420 FAPPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS FI. GENERAL INSTRUCTIONS: [ ] L Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. 2. Include a detailed site map on a separate sheet ofpaper, showing the location of the tanks(s), piping; streets, adjacent properties(north toward the top of rhe�page), nearby septic tanks, leachfields,water wells, buildings, underground public utility Iines(including water, sanitary sewer and storm sewer). and distance of piping from tank to dispensers. If underground utilities are not included on the site trap, you must state F_; in writing that USA Dig will be contacted prior to excavation activities. I 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". [ ] 4. Complete page 9, "Authorization to Release". This form trust be signed and dated by the k OWNER/OPERATOR of the facility. [ ] 5. Submit the appropriate fees and complete page it, the 'Underground Storage Tank Program Fee + Worksheet". 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division(PHS-EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this forth is completed and returned to PHS-EHD within 30 days of the tanks removal. [ ] 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. [ ] 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate". as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-11. it [ ] 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- EHD approval of the closure plan. [ ] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified,an addendum will be required with a S78.00Ihour fee and the review will begin on the date of resubmittal. [ ] 1 l. Submit verification of the fire permit from the appropriate fire district at the removal inspection. F [ ] 12. Advance inspection notice of at least 43 hours is re aired by PHS-EHD. EH 23 046 (Revised 9111196) Page I Fa Division of 5-in Joaquin Count' Health Care cervices