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PUBLIC FWALTH SERVICES SAN JOAQUIN COL: TY F � FN �� ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer SEP J 304 East Weber Avenue, Third Floor • Stockton, CA 9520_NV1_4Na;t, ¢ ;A� 209/468-5420 PERWIV I SFRM E41` APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE T.kN-KS STORLNG HAZARDOUS MATERIALS i. GENERAL INSTRUCTIONS: (] Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. [ ] Include a detailed site map on a separate sheet of Gaper, showing the location of the unks(s), piping. strew, ad',acent properties (none toward the too or me page), nearby septic tangs, leachnelds, water wells, buildings. underground pubiic utiiiry iines (including water. sanitary sewer and storm sewer;, and distance or piping _�om 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. a Complete page 3, "Application for Underground Storage Tank CIosure Permit". ComDlete page 9, "Authorization to Release". This form must be signed and dated by the OW'N'ER/OPERATOR of the facility. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee Worksheet". 6. Complete all questions on page 10. the Public Health Services -Environmental Health Division (PHS-EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is comp_ ieted and returned to PHS-EHD within 30 days of the tank removal. [ ] Submit a "Site Health & Safety Plan" 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. [ ] 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments. pursuant to the Uniform Building Code STD 70-11. [ ] 9. Obtain a "Grading and Excavation Permit" from the City of am Building Division prior to PHS- EHD approval of the closure pian. [ ] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a 578.00/hour fee and the review will begin on the date of resubmittal. [ ] 11. Submit verification of the fire pe -mit from the appropriate fire district at the removal inspection. [ ] 12. Advance inspection notice of at least 48 hours is recuired by PHS-EHD. EH 23 046 (Revised 9/11196) Page 1 A Division of San Joaquin County Heaith Care Services