Laserfiche WebLink
4 4 <br /> 7 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> PO U I N S 3 UIN COUNTY Unit Supervisors <br /> o co S <br /> E.H.S. Carl Borgman,R.E.H.S. <br /> Donna K.Reran,R <br /> 304 East Weber Avenue,Third Floor Mike Huggins,R.E.H.S,R.D.I. <br /> w Director California 95202-2708 <br /> Al Olsen,R.E.H.S. Stockton, Douglas W.Wilson,R.E.H.S. <br /> Margaret La orio,R.E.H.S. <br /> Program Manager 'I'810phone: (209)468-3420 Robert McC ellon,R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. Fax: (209) 464.-0138 <br /> Mark Barcellos,R.E.H.S. <br /> Program Manager <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATES <br /> RIAL <br /> 1. GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. Answer all questions,leaving no blanks. One copy will be returned to <br /> [J 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 : SamRLmg firm <br /> [] shall be an indeyendent third early from the contractor. <br /> [J 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 /> [J <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 t <br /> the County of San Joaquin Building Department and the incorporated City Building Dep <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 /> j J 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 $89.00/hour fee and the <br /> review will begin on the date of resubmittal <br /> jJ <br /> 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> j J 12. Advance'inspection notice of at least 48 hours is reauired 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 /> EH 23 046 (Revised 3/15/02) Page 1 <br />