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z PUBLIP HEALTH SERWICES SAN JOAQUIN cowry ENVIRONMENIAI1 IIIAIJAT11 DIVISION 1�rlles(M. Fli,jirlloto, M.I)., IVI.I'.II., Acting MOM Officer 445 N. San Jonrinin Shed • P. O. Box 388 • Stockton, CA 95201-0388 209/468-3420 AI'1'I,ICA'TION FOR 111A MIT TO CLOSE UNIXIMHOUNU S'l'UItA(;E TANKS S'I*URING HAZARDOUS MATERIALS OENERAL INSTRUCTIONS: (� I. Submit all Informal foil In triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with conrinenls. 2. Inciude a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, streets, adjacent properties (north townrd the top of the page), nearby septic tanks, leachfields, water welts, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included on the site map, you must state In writing that USA Dig will be contacted prior to excavation activities. I [ 3. Complete page 3, "Applicntion for Underl;round Tank Closure Permit". (� 4. Complete page 9, "Atillim kriflovi to Itelense A111nlyticnl Dntn". This form must be signed and dated by the OWN LIVOPERATO It of lite facility. (j S. Submit the appropriate fees and complete page 11, the "Underground'Tank Progrnm flee Worksheet". (( 6. Complete all questions on page 10, the Public Ilealth Services -Environmental Health Division (PIIS-F_,l ID) "thnlcrground Stornge 'Tmnk Disposition Tracking Record", except those requiring a signature and date of tank tentoval. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PIIS -EI -ID within 30 days of the tank removal. [ 7. Submit a "Site Ilenith & 81111ety 1'11111" 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. (f 8. If facility is located outside of the city limits, submit a "1lnckfiq rxenvatlon Certlflcnte" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code S'I'D 70-11. (� 9. Obtain a "landing mnd Exc11vntionn Permit" from the City of Tracy Building Division prior to PHS - MID approval of the closure plan. (I 10. The maxinlunl review (line for Closure Plans is 15 working days from receipt of the adequately cotupleted plan. If gross deficiencies are identified, an addendum will be requited with a S78.00/ lour fee (,ltd the review will begin on the date of resubmittn(. [ I 11. Submit velifk:ation of the fire permit from the appropriate fire district at the removal inspection. (� 12. Advance inspection notice of at least 48 hours is required by PHS -El ID, FI1 23 M7 (Revised I I/1/92) Page t A 010sinn of San .fonquin county Iteanh Care Services