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San Joaquin cunt <br /> it <br /> . 4Department DIRECTORDonna Heran,RE MS <br /> 1868 E. Hazelton Avenue <br /> Stockton, California ROGRA <br /> RDINATORS <br /> ; Robert McCietton,R11,IS <br /> 0zabs' : www.sjgov.org/ehd ,telt Cir HS'Ego, <br /> Phone: 209)466-3430 y a , R <br /> ( l�nda Tse t#e,REI <br /> E=1iS <br /> Fax: (209)464-3433 <br /> APPLICATION N STORAGE TANK <br /> I. <br /> ENERAL INSTRUCTIONS: <br /> 1) <br /> Submit all information in triplicate. Answer all questions, leaving no blanks, One copy will be returned to the <br /> pplicant with comments. <br /> . Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s),piping, streets, <br /> (1 <br /> djacent pr (north toward the top of the page), nearby septic tanks, leach ds, water wells, buildings, <br /> rground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from <br /> nk to dispensers. if underground utilities are not included on the site map, you must state in writing that IDSA <br /> ig will be contactedpi to excavation activities. <br /> 1 I <br /> Complete pages 3.5, "Application for Underground Storage Tank Closure Permit". o !n-4.fi <br /> ni <br /> t jComplete page 8, "Au tion to Release", This form must be signed and dated by <br /> the <br /> ERIOPERATOR of the facility. <br /> 1 j . <br /> Submit a*Service Request"form with the appropriate fees,submit completed UPC forms for Facility and Tanks <br /> rly State A&B s)a "Underground Storage Tank Program Fee Argo t". <br /> [] Complete all questions on page 9.the Environmental Health Department(EHD)"UrWarground Storage Tank <br /> position Tracking ord",gx t t o r uieino a sig re and date gf tank rem I. The of the <br /> 'tshall be responsible for ensuring that this form is completed and returned to EHD within 30 days of the <br /> nk removal. <br /> [] <br /> Submit a"Site Health&Safety Plan"as an addendum to this application,to address all potential hazards for <br /> is specific job site. Refer to the Site Safety Plan Guidance Document fors . <br /> [] if facility is located outside of the city limits, submit a "Backfill Ex va' te" as required y the <br /> unty of San Joaquin Building Department and the incorporated City Building Departments. pursuant to the <br /> niform Building Code STD 70-11. <br /> 1] <br /> Obtain a"Grading and Excavation Permit"from the City of Tracy Building Division prior to the Environmental <br /> ealth Department(EHD)approval of the closure plan. <br /> l] 0. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed <br /> an. If gross deficiencies are identified,an addendum will be required with a$125.00/hour fee and the review will <br /> in on the date of resubmittal. <br /> 1 j 1.Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> j 2.Advance inspection notice of at least 48 hours is required by EHD. <br /> 1 j 3.If planning to over-excavate at timis of UST removal,see"111. SITE MITIGATION"on Page 2. <br /> teH 23 6 (Reviged 1 130 12) i <br />