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f M , PUBLIC HEALTH SERVICES 0000/9 SAN JOAQUIN COUNTY Jogi Khanna M.D., M.P.H. i .. Health Officer 11. 0. Box 2009 (1601 East Hazelton Avenue), Stockton. California 95201 (209) 468.3400 APPLICATION FOR PERMIT TO C_LOa UNiDERGROUND STORAGE TANKS_STORING HAZARDOUS MATERIALS GENERAL INSTRUCTIONS: [ ] 1. Submit all information in triplicate. Answer all questions,leaving no blanks. One copy will be returned to the applicant with continents. [ ] 2. Include a detailed site map on a separate sheet of paper,showing the location of the tank(s).piping.streets.adjacent properties(north toward the top of die page).nearby septic tanks,leachfteids.wells,buildings.underground public utility lines(including water,sanitary sewer,and storm sewer).and distance of piping from 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. [ ] 3. Complete page 3. 'Application for Underground Tank Closure Permit". ( ] 4. Complete page 9. "Authorization to Release Analytical Data". This form must be signed and dated by the OWNER/OPERATOR of the facility. ( ) 5. Submit the appropriate fees and complete page 11. the"Underground Tank Program Fee Worksheet". ( ] 6. Complete all questitxts on page 10.the Public Health Services-Environmental Health Division(PHS-EHD) "Underpnound Storage Tank Dispusiting Tracking Record". except those requiring a signature and date of tank removal. The holder of die permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD within 30 days of die •removal. ( ] 7. Submit a "Site Health &Safety Man"as an agendum to this application.to address all potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. ( J 8. If facility is Imated outside of the city limits,subinit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and die incorporated City Building Department.pursuant to the uniform Building Code STD 70-11. [ ] 9. Obtain a "Grading and Excavation Permit" from due City of Tracy Building Division prior to PHS-EHD approval of the closure plan. ( ] 10. The maximum review time for Closure Plans is 15 worsting days from receipt of the adequately completed pian. If gross deficiencies are identified,an addendum will he required with a$78.00/bdxr fee and the review will begin on the date of resubmittal. [ ] 11. Submit verification of the fire permit from die appropriate fire district at due removal inspection. ( ] 12. Advance insrton notice of at least 48 hours is rent tied by PHS-EHD EH23 007(11/1/92) 1