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s PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> Jogs Kbaana M.D« M.P.H. <br /> Healtb Officer <br /> P. O. Box 2009 (1601 East Hazelton Avenue), Stockton, California 95201 <br /> (209) 468.3400 <br /> • apPucA rt Fog p _RMTT To t_oS �e p. <br /> ..,c•...+fln.r`*e* CTnr!♦ TANKS CTQRiN� t3AT.ARD®US MATPRIALS <br /> GENERAL INSTRUCTIONS: <br /> 111. Submit all infammuion in triplicate. Answer all questions,leaving no .'One copy will be rammed to the <br /> applicant with comments. <br /> [ ] 2. Ystclude a detailed site asap on a separate shat of paper.showing the location of the tank(s).Aping,streets.adjacent <br /> pvpades(north coward the top of the page).nearby septic tan im.leacttftelds,wells,buildings,underground public <br /> utility litres(including water.sanitary sewer,and storm sewer).and distance of piping from tank to dispensers. If <br /> underground utilities are ant included an the site map.you must state in writing that USA Dig will be <br /> contacted <br /> pion to excavation activities. <br /> [ , 3. Complete page 3. "Application for Underground Tank Closure Permit". <br /> [ j 4. Complete page 9."Antborization to Release Analytical Data". This form must be signed aM dated by the <br /> OWNE VOPERATOR of the facility. <br /> [ j S. Submit tttc appropriate fees and Complete page 11,the"Underground Tank Program Fee Worksheet". <br /> [ 1 6. Complete all questions on par 10.the Public Health serAm-EaviocruneaW Health Division(PHS-EFS) <br /> Underground Storage Tank Dispositing Tracking Record requiring a signature and dace <br /> ( of tank rianoval. The bolder of the permit ftU be aVonsible for amain dw this form is completed and <br /> returned <br /> PHS-EHD w"30 days of the tank removal. <br /> [ l 7. Submit a"Site & Safety piano as an addendum to This applicatim.to address all potential hazards for <br /> this <br /> spedfic.job sit. Reefer to the Site Safety Plan Guida=Doctanent for specifiCL <br /> [ 18. If facility is outside of the City limits,submit a"Backr I Ezavation Certir te" as roquired by the <br /> County of San Joaquin Building Deparmcm and the ircorporawd City Building Deparormt.pumant to the uniform <br /> 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 CIO$=plan. <br /> 10. The maximum review time for Closure Plato is 15 days Som receipt of the adequately completed plan. If <br /> Bross deficiencies we identified,an addendum will be required wilt a MMIbour fee and the review will begin on the <br /> date of resubmittal. <br /> [ j 11. Submit wrification of the fire permit foam the appvpriate fire district at the <br /> [ , 12. A&mc <br /> R ES is tt�±u'+_+r rlt by 1 LS-films_ <br /> EH23 007(1111/92) <br /> 1 • <br />