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►1 PUKICHEALTH SPRVICEc,% <br /> SAN JOAQUIN COL:iTY <br /> JOGI KHANNA M D li PH <br /> Haim Officer ; + •„ •' <br /> P O Box 2009 • (1601 Fist ELuclwn' Avenue) • $uxiaan, C:Lfora�a 95201 A -� .f c�► i� '`(209) 468.3400 "AY <br /> F- <br /> 1IJ92 <br /> AFPUQ—k7T0N FOR PERMIT TO CI,pSE <br /> UNDERGROUND STORAGE I&bM STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> I Submit all information m triplicate. One copy is returned to the applicant with comments. <br /> 2. Include a detailed site map, on a separate s <br /> p para heel of paper, showing tank lacauon and type, piping, <br /> streets and adJaceat properties(north toward the top of the page),locauou of the nearby septic tanks, <br /> ieachhelds,weLls,buaIf'ings,underground public utility lines(including water,sanitary sewer and storm <br /> sewer), and distance of piping from tank to dispensers. <br /> 3. Complete page 3, 'APPLicatioa for Underground Tank Closure Permit' <br />' 4 ComDletea <br /> p ge 9> Authoriziltlon W Release rl.riulytscai Data' <br /> 5 Submit the appropriate fees and complete page 11, the'Underground Tank Program g FeeWorksheet, <br /> 6- Describe on pages 4&5 the decontammauon techniques if applicable,material(s) utilized for nnsate, <br /> transportation and/or storage of Hazardous waste generated on site, and specify the responsible <br /> pariy(ies) who wit be disposing of waste generated on site <br /> 7 Descnbe on page 5 the method for purging and/or merting tank(s) and piping. <br /> 8 Describe on page 5 in detail how soil and/or water samples beneath the tanks and i in will obtained. ( ) pip g ll be <br /> 9 Complete theertinent sectlo <br /> P a of page 10,the Public Health Samces-Environmental Health Division <br /> (PHS-EHD) 'Underground Tank Disposition Tracking Record- The holder of the permit shall be <br />' responsible for ensunng that this form is completed and returned to PHS-FIM <br /> 10. Submit a 'Site Health & Safety Plan", as an addendum to this application, to address all potential <br /> hazards for this specific Job site. Refer to Site Safety Pian Guidance Document for specifics. <br /> 11. Submit a 'Compaction Report"as required by the County of San Joaquin Building Department and <br /> it`s incorporated City Buildmg Departments, pursuant to the Uniform Building Code STD 70-1. <br />' 12. Obtain a "Grading and E�=vatto • <br /> n Permit from the CIty of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> ( 1 13- 'Die ma3amum review time for Closure Plans is 15 working days from <br /> Ipt of he adequately <br /> completed pian. If gins dc. d=ctes are identified,an addendum wtU be required twith a S53-00/hour <br /> fee and the review will begin oa the date of resubmittal. <br /> ( j 14. Submit verification of the fire pe=t from the appropriate fire dastnet (pnor to scheduling re Aval <br /> inspection). <br /> ( � 15. Advance tnsg2Ltlq0 notice of at teat 48 hours is re wired by Public Health Sernces. <br /> EH23.007 (1110192) <br /> PAGE 1 <br /> A DWa=of Sas)M*M Coapt'Heakh Cuc Savx= 1 <br />