|
PqurN
<br />Q• ,
<br />cq��Foa`'�P
<br />ENVIRONMENTAL0 0
<br />DEPARTMENT
<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 • x . s .
<br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS
<br />GENERAL INSTRUCTIONS:
<br />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". of . 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. 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 />8. 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 Permit" from the City of Tracy Building Division prior to EHD
<br />approval of the closure plan.
<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 $93.00/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 />FH 23 046 (Revised 10/16/03) Page 1
<br />SAN JOAQUIN COUNTY
<br />Donna K. Heran,
<br />R.E.H.S.
<br />304 East Weber Avenue, Third Floor
<br />Director
<br />Al Olsen, R.E.H.S.
<br />Stockton,
<br />California 95202
<br />Program Manager
<br />Telephone: (209) 468-3420
<br />LauriCtulla,
<br />R.E.H.S.
<br />Fax: (209) 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 • x . s .
<br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS
<br />GENERAL INSTRUCTIONS:
<br />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". of . 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. 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 />8. 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 Permit" from the City of Tracy Building Division prior to EHD
<br />approval of the closure plan.
<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 $93.00/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 />FH 23 046 (Revised 10/16/03) Page 1
<br />
|