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SERCESPUBLI HEALTH _:. ..y <br /> Y +� SAN JOAQUM COUNTY <br /> JOGI KHANNA M.0..M.P.H. <br /> o- <br /> Health Officer <br /> V' 1 <br /> �l�UR <br /> V P.O. Box 2009 (1601 Bast Ha2etton Avrnue) •Stockton.C2lifomi2 95201 <br /> (209)468.3400. .,. <br /> i APPLICATION FO PERMTT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> , <br /> GENERAL, INSTRUCTIONS: J <br /> ( } 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One Dopy will be <br /> returned to the applicant with comments. <br /> 2. Include a detailed site map on a sethe tanksF(s),piping, <br /> parate sheet of paper,showing the location of <br /> [ ] streets,adjacent properties(north toward the top of the page),nearby septic ta <br /> wells, buildings, underground public utility lines (including wanks,leachfields,water <br /> i ter, sanitary sewer and storm sewer), <br /> and distance of piping from tank to dispensers. If underground utilities are not included.on the site <br /> map,you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> (] 3, Complete page 3, "Application for Underground Tanis Closure Permit'. <br /> T ,1 ti <br /> [ ] 4. Complete page 9, 'Authorization to Release Analytical Data". This form must be signed and dated <br /> by the OWNERIOPERATOR of the facility. - <br /> [ � 5,ii Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet". <br /> jj <br /> [ ] 6. ' Complete all questions on page 14, the Public Health Services-Environmental Health Division <br /> (PHS-EHD) "Underground Storage Tank Disposition Tmcldng Record", except those requiring a <br /> signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PHS-EHD 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 <br /> hazards for this specific Job site: Refer to the Site Safety flan Guidance Document for specifics. <br /> [ ] & If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-IL <br /> [ ] 9: Obtain a 'Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> I0. The maximum review time for Closure Plans is 15 working days from receipt of the adequately <br /> [ ] completed plan. If gross deficiencies are identified,an addendum will be required with a$53.00/hour <br /> fee and the 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 /> [ ] 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> L <br /> EH 23 007 (Revised 7110192) Page 1 <br /> LF A DM*wt of San Jmquin Counry Health fire Services I <br />