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a <br /> D <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst,M.D.,M.P.H.,Health Officer ., <br /> 304 East Weber Avenue,Third Floor°Stockton,CA 95202 %Fi3N� <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. Answer all questions,leaving no blanks. One copy will be returned to <br /> 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 :Sampling firm <br /> shall be an independent third party from the contractor. <br /> [] 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> [] 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> [] 6. Complete all questions on page 10,the Public Health Services-Environmental Health Division(PHS-EHD) <br /> "Underground Storage Tank Disposition Tracking Record",except those requiring a signature and date <br /> of tank removal_ The holder of the permit shall be responsible for ensuring that this form is completed and <br /> returned to PHS-EHD within 30 days of the tank removal. <br /> [J 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 /> [J 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate"as required by <br /> the County.of San Joaquin Building Department and the incorporated City Building Departments,pursuant <br /> to the Uniform Building Code STD 70-11. <br /> [J 9. Obtain a "Grading and Excavation Permit"from the City of Tracy Building Division prior to PHS-EHD <br /> 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 S89.00/hour fee and the <br /> 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-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 8/1/01) Page 1 <br /> A Division of San Joaquin County Health Carc Services <br />