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<br />APPLICATION FOR PERMIT TO CLOSE
<br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS
<br />GENERAL INSTRUCTIONS:
<br />[t 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the
<br />applicant with comments.
<br />{
<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, underground
<br />public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If
<br />underground utilities are not included on the site map, you must state in writing that USA Dig will be contacted prior to
<br />excavation activities.
<br />yJ 3. Complete pages 3-6, "Application for Underground Storage Tank Closure Permit". Fof : Sampling firm shall
<br />/ be an independent third party from the contractor.
<br />[v7 4. Complete page 9, "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 10, the Environmental Health Department (EHD) "Underground Storage Tank
<br />Disposition Tracking Record", exceot those requiring a signature and date of tank removal The holder of the permit shall
<br />be responsible for ensuring that this form is completed and returned to EHD within 30 days of the tank removal.
<br />7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this
<br />specific job site. Refer to the Site Safety Plan Guidance Document for specifics.
<br />ho� 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 Uniform
<br />Building Code STD 70-11.
<br />[ ] 90 JA Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of
<br />the closure plan.
<br />[ ] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If
<br />gross deficiencies are identified, an addendum will be required with a S115.00/hour fee and the review will begin on the
<br />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 rmuircd by EHD
<br />[ ]
<br />13. Submit Contingency Plan for over -excavation at time of UST removal (if planning to over -excavate).
<br />See "III. SITE MITIGATION" on Page 2.
<br />EH 23 046 (Revised 07/31/09)
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />A"A4t"
<br />SAN JOAQUIN COUNTY
<br />r' 3
<br />Donna K. Heron, R.E.H.S.
<br />Unit Program Coordinators
<br /><
<br />Director 600 East Main Street
<br />Carl Borgman, R.E.H.S.
<br />• - _
<br />Stockton, California 95202
<br />Mike Huggins, R.E.H.S., R.D.I.
<br />•. :Y'•
<br />Laurie A. Cotulla, R.E.H.S. Tele hone: 209 468-3420
<br />P ( )
<br />Margaret Lagorio, R.E.H.S.
<br />RobertMcClellon, R.E.H.S.
<br />Assistant Director
<br />Fax: (209) 468-3433
<br />Jeff Carruesco, R.E.H.S.
<br />Kasey Foley, R.E.H.S.
<br />APPLICATION FOR PERMIT TO CLOSE
<br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS
<br />GENERAL INSTRUCTIONS:
<br />[t 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the
<br />applicant with comments.
<br />{
<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, underground
<br />public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If
<br />underground utilities are not included on the site map, you must state in writing that USA Dig will be contacted prior to
<br />excavation activities.
<br />yJ 3. Complete pages 3-6, "Application for Underground Storage Tank Closure Permit". Fof : Sampling firm shall
<br />/ be an independent third party from the contractor.
<br />[v7 4. Complete page 9, "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 10, the Environmental Health Department (EHD) "Underground Storage Tank
<br />Disposition Tracking Record", exceot those requiring a signature and date of tank removal The holder of the permit shall
<br />be responsible for ensuring that this form is completed and returned to EHD within 30 days of the tank removal.
<br />7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this
<br />specific job site. Refer to the Site Safety Plan Guidance Document for specifics.
<br />ho� 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 Uniform
<br />Building Code STD 70-11.
<br />[ ] 90 JA Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of
<br />the closure plan.
<br />[ ] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If
<br />gross deficiencies are identified, an addendum will be required with a S115.00/hour fee and the review will begin on the
<br />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 rmuircd by EHD
<br />[ ]
<br />13. Submit Contingency Plan for over -excavation at time of UST removal (if planning to over -excavate).
<br />See "III. SITE MITIGATION" on Page 2.
<br />EH 23 046 (Revised 07/31/09)
<br />
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