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PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer , 304 East Weber Avenue,Third Floor • Stockton, CA 95202 209/468-3420 APPLICATION FOR PERINIIT TO CLOSE UNDERGROUND STORAGE TAN S STORING HA► ARDOUS MATERIALS I. GENERAL INSTRUCTIONS: ( } 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. (] 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s),piping,strgets, adjacent properties (north toward the too of the page), nearby septic tanks, leachftelds, water 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 Storage Tank Closure Permit". LVot : Sampling firm shall be an independent third parry from the contractor. /tf�c�es �eou�4lr�ttu 1,J 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the OWNEWOPERATOR of the facility. -4,d fZ� ( ) 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee Worksheet". Rcr ✓o..at *o CC, // ecw>Sr o.� 4111.4v1 s e& . (J 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS-EHD) "Underground Storage Tank Disposition 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-EHD within 30 days of the 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 Plan Guidance Document for specifics. .7 c.,///Sjuer}"�t>,�! aid, [ ] S, If facility is located 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 Departments, pursuant N� to the Uniform Building Code STD 70-11. [ ] 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD f(/4 approval of the closure plan. [] 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 %ill be required with a 539.00/hour fee and the review«;11 begin on the date of resubmittal. l i. Submit verification of the fire permit from the appropriate fire district at the removal inspection. (? J ( ] 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. 13. Subrtut Contingency Plan for over-excavation at time of UST%movai(if planning to over-excavate). See"III. SITE MITIGATION..on Page 2. EH 23 046 (Revised 3/1/01) Page I A Division of San;oaquin Councv Hnith Care Ser:icrs