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PUBL?,'HEALTH SE11VICES <br />p?a��N C <br />).• c� cft •.O <br />SAN JOAQUIN COUNTY 2: i <br />IN <br />ENVIRONMENTAL HEALTH DIVISION Q <br />Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer 3 <br />445 N. San Joaquin Street • P. O. Box 388 • Stockton, CA 95201-0388 <br />209/468-3420 <br />APPLICATION FOR PERMIT TO CLOSE <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 <br />returned to the applicant with comments.��� �, F f� -�tL 4. r C�510D)1 S i b , / i <br />lei [ 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_pnor to excavation activities. <br />LW &1j j b <br />� l�to <br />i <br />( ] 10. <br />Complete page 3, "Application for Underground Tank Closure Permit". <br />Complete page 9, "Authorization to Release Analytical Data". This fo m ust be signed and dated <br />by the OWNERIOPERATOR of the facility. ti ri) e � b +�► t o <br />Submit the appropriate fees and complete page 11, the "Underground Tank Program Fee Worksheet". <br />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 />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 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 70-11. <br />Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br />EHD approval of the closure plan. <br />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 S78.00/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 />EH 23 007 (Revised 11/1/92) <br />Page 1 <br />13. I c- w o r K S AJA S -�b �# �S �-• vltie_ <br />A Division of San Joaquin County Health C4re Services <br />