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PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY 00ni Jogi Khanna M.D.. M.P.H. Health Officer P. O. Box 2009 (164)1 East Hazelton Avenue). Stockton. California 95201 (209) 468-3400 apt to'ATION FOR PPRtif[T TO CLOSE ..:,I E ayh % ) A(;E TAVKti S ING HAZARDOUS MATERIALS GENERAL INSTRUCTIONS: ( j 1. Submit all information in triplicate. Answer all questions. leavinz no blanks. One copy will be returned to the applicant with cununents. ( ) 2. Include a detailed sue map on a ser trate sheet of paNr.showume rite 4x:au0n of the tank(s). piein__. streea.adi.icent prOpenres(north toward the top of the page).nearby septic tanks.leachtields.wells.buildings. underground public utility lines(including water.saintary sewer.and storm sewer).and distance of piping from tank to dispenser. If underground utilities are not included on the site trap.you must state in wntinc that USA Dig will be contacted prior to excavation acuvaies. [ ) 3. Complete page 3. "Application for Undergn►und Tank Closure Permit". [ J 4. Complete pave 9. "Authorizatkin to Release Analytical Data". This form must be signed and dated by the Ow-4MOPERATOR of the facility. ( j S. Submit the appropriate fees and complete page 11. the "Underground Tank Program Fee Worksheet". [ ] 6. Complete all questions out page 10.the Public Health Services-Environmental Health Division(PHS-EHD) "Underground Storage Tank Tracking Record". except those requiring a signature and date of tank remoVal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS- Ewithin 30 days of the tank removal. ( ] 7. Submit a "Site Health do Safety Plan" as an addendum to this application.to address all potential hazards for this specific job site. Refer to the Site Safety Pian Guidance Document for specifics. [ j 8. If facility is (orated outside of the city limits. submit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Deparimient.pursuant to the uniform Building Code STD 70.11. [ J 9. Obtain a"Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD approval of the closure plan. ( ] 10. The maximum review time for Closure Plans is 14 working days from receipt of the adequately completed plan. If gross deficiencies are identified.an addendum will be required with a S78.0()/hour fee and the review will begin on the date of resubmittal. [ ] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. ( ] 12. Advau . :.,�.�reion nonce of at leapt 46 hours is reagi�A by P SH FHD- EH23 007(11/1/92) l