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0 i <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street <br />Stockton, California 95202-3029 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 464-3433 <br />DIRECTOR <br />Donna Heran, REHS <br />PROGRAM <br />COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />CLOSURE PERMIT <br />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. l <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 $125.00/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 8/1/11) 1 <br />