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PUBLIC HEALTH SE <br />SANJOAQUIN COUNTY <br />JOGi KHANNA AD.. M.P.H. <br />Hellin Officer <br />juyy <br />P.O. Box 2009 + (1601 .East Hazetton Avenue) • Stockton, Califomia/95$o� <br />( 209) 469-3400 1995 <br />APPLICATION FOR PERMIT TO CLOSE E /�EftI4 y <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MA C <br />GENERAL INSTRUCTIONS: <br />[ ] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be <br />returned to 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, <br />streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water <br />wells, buildings, underground public utility lines (including water, 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 Tank Closure Permit'. <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 />ru a �••• -:.,�•:��a►�.�- r' rr: yrrrra rirur,rr :.'�,r <br />[ j 6. Complete all questions on page 10, the Public Health Services -Environmental Health Division <br />(PHS-EHD) 'Underground Storage Tank Disposition Tracking 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 Plan Guidance Document for specifics. <br />(] & If facility is located outside of the city limits, submit a Backfill E�Ceavatlon 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 70-11. <br />[ ] 9. Obtain a 'Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS - <br />FI -ID approval of the closure plan. <br />[ ] 10. The mwdmum 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 S53.00/hour <br />fee 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 removal inspection. <br />[ ] 12. Advance inspection notice of at least 48 hours is required by PHS -E1 -TD. <br />EH 23 007 (Revised 7/10/92) Page 1 <br />1 Divisirnt of Vq J+ut t'iwnry Health < aiC XtNct^J C� <br />