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4 U San Joaquin County <br /> Environmental t DIRECTOR <br /> 1868 E. Hazelton 'U Donna Heran,RE <br /> Stockton California 95205-6232 I <br /> °, °` ,•+ � COOKDiNOC?� fiTOFtS <br /> Recker!McClelten. FtIS <br /> 'Websites: www.sjgov.orglehd eFt � 1 <br /> Phone: (209)468-3420 Un da Turkat'te,RE S <br /> Fax: (209)464-3433 <br /> APPLICATION STORAGE TANK <br /> CLOSURE <br /> 1. GENERAL INSTRUCTIONS: <br /> E] <br /> I. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be retu to the <br /> 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 p (north toward the fop of the e), nearby septic tanks, leas hfieids, watewr wells, ildings, <br /> underground public utility fines (including water, sanitary sewer and storm sewer), and distance of pi g from <br /> tank to dispensers. If underground utilities are not included on the site map, you must state in writting at USA <br /> Dig will be contacted prior to excavation activities. <br /> [) . Complete pa 3-5. "Application for Underground Storage Tank Closure Permit". t Sam i firm <br /> shall bean inftpM342nt third Ra LrfftroMmjtbhScMtRctor. <br /> E] 4. Complete page 8, "Authorization to Release. This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> [j 5.Submit a'Service Request form with appropriate fees,submit completedUPC forms for F 'lity a Tanks <br /> (formerly State A&B s)and complete the*Underground Storage Tank Program Fee WorksheeV. <br /> E 6.Complete all questions on page 9,the Environmental Health Department(EHO)"Underground$to Tank <br /> Disposition Tracking Record",2XQMA thoM reguiring a signature and dote of tank removal, The hhD1 of the <br /> permit shall be responsible for ensuring that this form is completed and returned to EHD within 30 d s of the <br /> tank removal. <br /> ( 7. Submit a"Site Health&Safety n"as an addendum to this application,to address alle i Ards for <br /> this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> C] 8. If facility is located outside of the citylimits, submit a "Backfill vat ion Certificate" as requi by the <br /> County of San Joaquin Building Department and the incorporated City Building Departments, pu to the <br /> Uniform Building Code STD 70-11. <br /> [) <br /> 9.Obtain a"Grading and Excavation Peimir from the City of Tracy Building Division prior to the Env# n ntal <br /> Health Department(EHO)approval of the Closure n. <br /> E j 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately pleted <br /> plan. If gross deficiencies are identified,an addendum will to required with a$125.00 r fee and will <br /> begin on the date of resubmittal. <br /> E l 11.Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [J 12.Advance inspection notice of at least 48 hours is required by E D. <br /> E j 13.If planning to over-excavate at time of UST removal,see'111. SITE MITIGATION"on Page 2. <br /> EI12;3 046 (Itcviswd 10/30/12) ) <br />