Laserfiche WebLink
SERVT C *N ��PUBLICFFALTH 1"- <br /> .' <br /> S JOAQUIN COT-71NTY �ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-0388 <br /> 209/468-3420 <br /> ?.PPLICATION FOR PER,,A" TO CLOSE <br /> ERIAI-S <br /> LTNUERGROUND STORAGE TANKS STORING �,Z�,RDOUS 1I�T <br /> 1. GENERAL INSTRUCTIONS: <br /> j 1 Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. <br /> Include a detailed site map on a separate sheet of paper. showing the location of the tanks(s), piping' <br /> 2. (north toward the top of the page), nearby septic tanks, lerchfields,water wells, <br /> streets, adjacent properties er and sewer), and <br /> buildings. ce <br /> underground pubt ility lines <br /> md utilitiing esa snot inclutary ded n the sstorm map, youu Must State <br /> ate <br /> of piping from tank to dispensers. <br /> in writing that USA Di; will be contacted prior to excavation activities. <br /> 3. Complete page 3, 'Application for Underground Storage Tank Closure Permit'. <br /> j 4. Comple[e page 9, <br /> "Authorization to Release This form must be sued and dated by the <br /> Ow,, j E:RATOR of the facility. <br /> Submit the appropriate fees and complete pace 11, the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> 6. Complete all questions on page 10, the public Health Services-Environmental Resit::. Division(PHS-EHD) <br /> ( ) Disposition Tracking Record", except those requi..ag a signature and date <br /> 'Underground Storage Tani: Dispos that :his form is completed <br /> of tank remoy�PH EHDger of the within 30 days of the bet shall responsible <br /> removal for ensuring <br /> and ,eturnei to <br /> . Submit a Site Health & Safety Pian" as an addendum to this application. to address all potential <br /> r job site. Refer to the Site Safety Plan Guidance Document for specincs. <br /> hazards .or this specific J <br /> g, lred <br /> If facility is located outside of the city limits, submit a "Backfill Excavation Certificate"Dc menu. <br /> by the County of San Joaquin Building Department and the incorporated City Building P <br /> pursuant to the Uniform Building Code STD 70-11. <br /> [ ) 9. Obtain a "Grading <br /> and �Yavation Permit" from the Ci <br /> ry of Tracy Building Division prior to PHS- <br /> EHD approval of the ciosure plan. <br /> 10. The maximum review time for Closure Plans is 15 working days from rec_:t)t of the adequately <br /> jo addendum will be required with a S 7 8.00/hour fee <br /> comple[ed plan. If gross deficiencies are identified. an <br /> and the review will begin on the date of resubmittal. <br /> 11. Submit verification of the fire permit from the appropriate fire district at the remoyalpection. <br /> t , Advance inspection notice of at lest -iS hours is required by PHS-EHD. <br /> 12 <br /> � ) <br /> EH 23 046 (Revise? 9/11/96) <br /> Pace 1 <br /> A D••c>>on J:sn Toa�,.•r.C�.n�•-eai:�Care=er:ice: <br />