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PUBLIC HEALTH SERVICES SAN JOAQUIN COLTtiTY '` A EIN-VIRONMENTAL HEALTH DIVISION ` Karen Furst, M-D., M.P.H., Health Officer ' 304 East Weber Avenue, Third Floor • Scockton, CA 9720 . 209f468-3420 dPPLICAMN FOR PER-MIT TO CLOSE UNDERGROUND STORAGE T.AuNKS STORLNG H.AZARDOCS MATERI.-xL.S 1. GENERAL INSTRUCTIONS: ( ] 1. Submit all information in triplicate. Answer all questions, leaving ao blanks. One cop;; will be returned to die applicant with comments. ( I 2. Include a detailed site asap on a separate sheet of paper, showing the location of he tanks(s), piping. streets, adjacent properties (north toward the top of the gage), nearby seprc ranks. leachileids, water wells, buildings, underground public utility lines (including water, sarutard y sewer anstores sewer), and distance of piping from tank to dispensers. If under ground utilities are not included on the site map, you must state in writing chat USA Dig will be contacted prior to excavation activities. i 3. Complete page 3. "Application for Underground Storage Tank Closure Permit". Note: Sampling firma snail be an independent third party from the contractor. [-� 4. Complete page 9, 'Authorization to Release". This fogs must be signed and dated by the OWNDUOPERATOR of the facility. [ 5. Submit the appropriate fees and complete page Lt. the "Underground Storage Tani: Program Fee Worksheet". (� 6. Complete ail questions on page 10, the Public Heaith Services-Eavironnsentai 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 res.onsfole for ensurrng that this form is comuleted and returned to FHS-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 Safery Plan Guidance Document for specifics. ( ]� S. If facility is located outside of the city limits, submit a "BackfM Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant 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 approval of the closure pian. 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 S78.00fhour fee and the review will begin on the date of resubmittal. [ 11. Submit verification of rhe fire permit from the appropriate Lire district at the removal inspection- Ll l 1?. Advance inst}ection notice of at ]east 43 hours is required by PHS-'EHD. EH 23 0046 iRevised 10119198) Paee t A:Dmsion or San