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San Joaquin County <br /> Environmental Health Department D/RacTOR <br /> Donna Heron,REHS <br /> r. 600 East Main Street <br /> N: Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> Robert McClellon,REHS <br /> •' • �____._®`� --— — Jed Carruesco,REHS,RDI <br /> c4' •., �P Website:www.sJgov.or9/ehd Kaaey Foley,REHS <br /> Phone: (209)468-3420 U f IMEIVED <br /> Fax: (209)464-0138 <br /> LO-IV* WL&..e 0V 2 4 2010 <br /> APPLICATION FOR UNDERGROUND STORAGE ETAWAENTALHEALTH <br /> CLOSURE PERMIT PERMIT/SERVICES <br /> I. GENERAL INSTRUCTIONS: <br /> [] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned 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 properties (north toward the top of the page), nearby septic tanks, leachfields, water wells, buildings, <br /> underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from <br /> tank to dispensers. If underground utilities are not included on the site map, you must state in writing that USA <br /> Dig will be contacted prior to excavation activities. <br /> [] 3. Complete pages 3-5, "Application for Underground Storage Tank Closure Permit". Not : Sampling firm <br /> shall be an independent third party from the contractor. <br /> [] 4. Complete page 8, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> [] 5. Submit a"Service Request'form with the appropriate fees, submit completed UPC forms for Facility and Tanks <br /> (formerly State A& B forms)and complete the"Underground Storage Tank Program Fee Worksheet". <br /> [] 6. Complete all questions on page 9, the Environmental Health Department(EHD) "Underground Storage Tank <br /> Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the <br /> permit shall be responsible for ensuring that this form is completed and returned to EHD within 30 days of the <br /> tank removal. <br /> [] 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for <br /> this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> [] 8. If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required by the <br /> County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the <br /> Uniform Building Code STD 70-11. <br /> [] 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to the Environmental <br /> Health Department(EHD) approval of the closure plan. <br /> [] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed <br /> plan. If gross deficiencies are identified, an addendum will be required with a$122.00/hour fee and the review will <br /> begin on the date of resubmittal. <br /> [] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [] 12. Advance inspection notice of at least 48 hours is required by EHD. <br /> [] 13. If planning to over-excavate at time of UST removal, see"III. SITE MITIGATION"on Page 2. <br /> EH 23 046 (Revised 07/22/10) j <br />