COMPLIANCE INFO_FILE 8 - Laserfiche WebLink

Home Browse Search

79 PUBLIC HEALTH SERVICES Q SAN JOAQUIN COUNTY Jogi Khanna M.D., M.P.H. Health Officer 1'. 0. Box 20419 (1601 East Hazelton Avenue), Stockton, California 95201 (209) 468-3400 APT CATiON FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS GENERAL INSTRUCTIONS: [ j 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 die location of time tank(s).piping,streets,adjacent properties(north toward the top of the page),nearby septic tanks,leaclhfheids,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 die facility. [ ] 5. Submit die appropriate fees and complete page 11, tie "Underground Tank Program Fee Worksheet". ( ] 6. Complete all questions on page 10,time Public Health Services-Environmental Health Division(PHS-EHD) "Underground Storage Tank Dispositing Tracking Record". except those requiring a signature and date J of tatik removal. The holder of Ute permit shall be responsible for ensuring that this form is completed and returned \ to PHS-EHD within 30 days of die tank removal. [ ] 7. Submit a "Site Health & Safety Plan"as an addendum to this application. to address all potential hazards for this specific job site. Refer to the Site Safety Piaui Guidance Document for specifics. [ ] 8. If facility is located outside of time city limits. submit a "Backfill Excavation Certificate" as required by time 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 die City of Tracy Building Division prior to PHS-EHD approval of the closure plum. j ] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified,an addendum will be required with a S78.00/hour fee and the review will begin on the date of resubmittal. [ ] 11. Submit verification of the fire permit front the appropriate fire district at the removal inspection. [ ] 12. Advance inaction notice of at least 48 hours is required by PHS-EHD. EH23 007(11/1/92) 1 _