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0 <br />TH SERACES <br />PUBLI HEAL <br />SAKI JOAQUIN COUNT <br />JOG1, KHANN A M. D., M.P H �( <br />Health Officer <br />P.O. Box 2009 0 (1601 East Hazelton Avcnue) O Stz* won, Cauc4nl3 91,701 <br />(2o9) 46s•3400 <br />APPLICATION FOR PEFINIrf TO CLOSE <br />iJN©EGRO[ NI3 ST�JRoGE TANiSS STORING tL►z�.�tDOGSi1TE LcLS <br />GENERAL INSTRUCTIONS: <br />Submit 2tt infarnlatis't in triplicate. One cony is returned to the applicant ��ith comments. <br />2, Include a detailed site map. on a separate sheet Of paper, shining tank location and We, piping, <br />streets and adjacent properties (north toward the top of the page), location of the nearby septic tanks. <br />leachiields, wells, buildings, under;rcuni public utility lines (including water, sanitary sewer and storm <br />sewer), and distance of piping frons tank, to dispensers. <br />3 Complete page 3, "APPlict'6011 for Underground Tank Closure- Permit". <br />(j 4. Complete page n, "Authorization to Release Analytical Data <br />J 5. Submit the appropriate fees and corinp'.ete page 11. the'Underground Tank Program Fee Work -sheet". <br />j 6. Describe on pages 4 `C 5 the :econta—urination techniques if applicable, materiai(s) utilized for rinsate, <br />f hazardous waste generated on site, and 5pCCifY the responsible <br />transportation atttl,`Or starag� o <br />parry(ies) v:llo will b -e dispo:ir.S of waste generated on site. <br />(J 7. Describe on page ✓ the Meth,d for purging and,Or inerting tank(s) and piping. <br />-. Describe on page -5 in detail hLI' soil and/or :eater s.,mp!es b.neath the tank(s) and piping will be <br />j obtained. <br />j 9. Complete the pertinent sectieit of page 10, rile Pt;t�lic Healtri Se�iC"s Er.�ironment:�l 1-iealth Division <br />(PHS-IrHD) "Underm+-oend Tank- Disroslticm TrccL,ng Record". 'tile roller of the permit shall be <br />responsible for ens'�riag thin this fb-irsl 'as COMPi'eted Sr, returned to F1 S-EHD. <br />j I0• Submit a "Site'Kealth & Snfery Plun", a: an sddenduni :o t"is applic-ion, to address all potcnrul <br />hazards ;or this specif jot. site. Refer to Site 53fery Pian Guida.�ce Document for specifics. <br />s J ii. Su>~r it a 'Compaction Rcpor:' 35 rc;l'1!r2d L`v tt..c County of San Jo-4quin Building Dcpartmer,l and <br />t it's it ' oeparnni -,its, r:rs:ant t. the. Lniforiri Atli?uing Code STD 70-1 <br />carpo:.:tech Cit�C Hui,Ji..g r l• <br />j and Ex:a:•ntior. Perralt' frorn Ci :v of Tracy Puilt;irg DMMO prior t0 PHS <br />12. Cbtain a 'Grading - <br />EHD approval of toe closure plan. <br />(' 13. The maximurn de,6iew titre ler Cicsure Pians is i '.Forting days freer. receipt of the sde.quately <br />' � dip r e �.re identi`ieJ. 3n a-3endurti'N1!1 Ie red with a SS S.t��t.+r:lOtlr <br />completed plan. I. ,t',iC55 fcien.. s <br />foe and therevi.w i:! begin on the ::ate of reSI;hM;tt;li. <br />14. Submit verification F the fii e. permits from the 2pp.Opr.3t.', lire disinct (Prior to Sci.eduling TernOYal <br />appointment). <br />j 15. Advan:e irs•�:etiU-� nOtiwe Cf at. Least •t'3 hotir• is re u. red by Lubiic Pe l0l SMices. <br />Page 1 M <br />iJ1_1 --J 3 <br />