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5-27-04; 8:43AM' 0 ;925 551 7888 # 23/ 34 <br /> 03/05/2004 13;59 2094683433 FIFTH FLOOR PAGE 05 <br /> PUBJLI(,�.. 1-71EALTH SERVIk"]VE's W ., <br /> .%W JOAQUW COUNTY <br /> EN�RONMENTAL�- DiVdS1;C7�N <br /> ,. <br /> Karen Furse,M.D.,M.P.H.,Health Officer <br /> 304 East Weber Avenue,Third Floor•Stockton,CA 95202 <br /> 2091468-3420 <br /> A KATION P0R M-v IT TO CLegE <br /> WNDERGROUND STQJ AGE tANKS STO a°G_RAZAIMOUS MATERIALS <br /> L GENERAL INSTRUCTIONS: <br /> J 1. . Submit al!information in triplicate. Answer all questions,leaving no blanks. One copy will be returned to <br /> the applicant with cor attents. <br /> 7 2. Includc a detailed site map on a separate shcct o(paper,shmNing the location of the tanks(#),piping streets, <br /> adjacent properties (north toward the top of the page), nearby septic tanks, leaehfielde, water wells, <br /> buildings,underground public utility litres(including water,sanitary sewer and storm stwer), and distance <br /> of piping from tank to dispcnscrs. If underground titilitics are not Included on the site map, you most state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> y1 3. Complete page 3, "Application for Underground Storage Tani:Closure Permit", of :Sarnp[it a Earn <br /> shall be an independent third r><y fbm the contractpri <br /> 4. Complete page 9, "Authorization to Release". This form must he signed and dated by the <br /> OYM EWOPERATOR of the facility. <br /> {) S. Submit the appropriate Etas and complete page 11, the "Underground Stomge Tani: Prograrn Fite � <br /> tiYafl:sheet". � <br /> [ 6. Complete all questions on page 10,the Public Health Services-Environmental Health Division(PHS.EFM) <br /> ' "Underground Storage Tank Disposition Tracldng Record",except chose requiring a signature and dare <br /> of tank removal. The holder of the pertttit shall be responsible for ensuring that this form is completed and <br /> returned to PHS-EHD within 30 days of the tank mram-al. <br /> 7. Submit a "Site Health&Safety flan"as an addendum to this application,to address all potential hazards <br /> for this specific job site. Refer to the Site Safety Plan Guidance Docurnertt For speciFics. <br /> {] S. If facility is located outside of the city limits,submit a "Backfill Excavation Certificate"as required by <br /> the County.of San foagttin Building Depanwent and the incorporated City Building Departinetus,pursuant <br /> to the Uniform.Building Code STD 70.1 t. - <br /> [3 9. Obtain a"Grading and Excavation Permit"from the City of They Building Division prior io PHS-ET.-ID <br /> approval of the closure plan. . <br /> [] I0. The wax imura review time for Closure Plans is 1$working days from receipt of the adequately completed <br /> plan. if gross deficiencies are identified, an addendum will be required with a $89.00/hour fee and the <br /> review%ill begin,an the date of cesubihittal. <br /> {J 11. Submir verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [j 12, Advance inspection notice of at least 48 hours is required by PHS-END. <br /> j 1 13. Submit Contingency Plan for over-excavation at tittle of UST removal(ifplantting to over-c-ma ate). <br /> Sec"111. SITE MITIGATION-on Pagc 2. <br /> ES 23141 (Revised 8/1101) Page 1 , <br /> A DIvidioa oFSan Joagwn County Health Caro Saivico <br />