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SAN JOAQUIN Environmental Health Department COUNTY— otnessgrows here . APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT 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, streets, adjacent properties (north toward the top of the page), nearby septic tanks, leach fields, 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 pages 3-5, "Application for Underground Storage Tank Closure Permit". Note : Sampling firm shall be an independent third party from the contractor. 4. Complete page 8, "Authorization to Release". This form must be signed and dated by the OWNER/OPERATOR kv/ of the facility. >� ] 5. Submit a "Service Request" form with the appropriate fees, submit completed UPC forms for Facility and Tanks f (formerly State A & B forms) and complete the "Underground Storage Tank Program Fee Worksheet' . r.]/ 6. Complete all questions on page 9, the Environmental Health Department (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 EHD within 30 days of the tank removal. r 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. 8. 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 to the Uniform Building Code STD 70-11 . [ ] 9. Obtain a "Grading and Excavation Permit" fr rrftfie City of Tracy Bwidi ivision prior to the Environmental Health Department (EHD) approval of the closur plan. G fS N��II�S • { — 10. The maximum review time for Closure Plans is 15 wor om receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a $152.00/hour fee and the review will begin on the date of resubmittal. . G , prate 1rci � t j'ee oval in 11 . Submit verificat�pn of the fire per rom the app priate fire di ict at the removal inspection. [ ] 12. Advance inspection notice of at least 48 hours is required by EHD. 13. If planning to over-excavate at time of UST removal, see "III. SITE MITIGATION" on Page 2, 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com