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SERVICES <br />PUBLICCEALTH <br />Pp U , ly <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION y� <br />Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br />304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-038'8`���C4�IFpR�\P <br />ys a o z- 2,;P) a 209/468-34200 /- 4 <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />I. GENERAL INSTRUCTIONS: <br />[� 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br />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 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 />[J,) 3. <br />Complete page 3, "Application for Underground Storage Tank Closure Permit". <br />4. <br />Complete page 9, "Authorization to Release". This form must be signed and dated by the <br />OWNER/OPERATOR of the facility. <br />5. <br />Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br />Worksheet". <br />[� 6. <br />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 <br />and returned to PHS-EHD within 30 days of the tank removal. <br />j� 7. <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 />[ 8. <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 />A[ 9. <br />Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br />�� <br />EHD approval of the closure plan. <br />[ ] 10. <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 fee <br />and the review will begin on the date of resubmittal. <br />=],ISubmit verification of the fire permit from the appropriate fire district at the removal inspection. <br />=]IAdvance inspection notice of at least 48 hours is required by PHS-EHD. <br />EH 23 046 (Revised 7/10/96) Page i <br />A Division of San Joaquin County Health Care Services <br />