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P U BLICi JEALTH SER)V4CES
<br /> SAN .IOAQUIN COUNTY
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<br /> ENVIRONMENTAL 111WAll DIVISION
<br /> trues( M. IhnJimolo, M.b., MAIM., Actiog Ileallh officer rrlrM8A1+ T.,
<br /> 445 N. Sall .11/nlllllll Silee, • 1'. O. Ions .lab • Stocklon, CA 95201•OJbb i
<br /> 1,19,�68.J421► a 3 i N� ��-, ec_.
<br /> AI't7.It:Aa'1VN Ft111 1'IRMfr'1_O CWSr ;
<br /> UNl/�IICIIUUNU 51_UItAGIs TANI(S STORING HAZARDOUS MA' TRIALS
<br /> OfiNERAL INS'('RUC1'IONS:
<br /> l L Subntil nil hdunnmion In ttlplicnle, Answer nil quesli0ns, leaving no blanks. One copy will be
<br /> tenoned to the Applicant with Comments.
<br /> tnrludc it dclnilcd site map on a scpnlale slice, of paper,showing the lornllou of the tanks(s), piping, , I
<br /> stteels, ndlaccll, pli(lclfiei (ImIlb toward the lop of the page),nearby sep,ic'lnnks,lenchfields,water
<br /> wells, buildings, ondaglound public aWlty linea (hlciuding water, sanitary sewer and storm sewer),
<br /> And dlslmlce of piping(joint tnak hr dispensers. If undergn/und utilities are not Included on the site
<br /> amp, you nilsl slate In willing VIVA( USA big will be comacled prior to excavall0u activities.
<br /> I 1. Complcic page 1, "AppllCnfiml fur lhnlergrnund 'fank Closure 1'ermll".
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<br /> 11. c'ninplete lenge,9, "Antho,knihn, to Itelense Annlyllcol train". 'Chis rutin nrust be signed and doled I,
<br /> by the O%Vt4IFII/O1'rltA'I Olt of file facility.
<br /> IX 5. Sll11n11t the Appnipiiale fees And cumplele page 11,the"Underground Tank Program Fee Worksheet".
<br /> ICY 6. Cingllcic nip gacsfions tit page 10, the Public Ileallh Services-Envitonmcnlal Ilenith Division
<br /> (1'lIS-IiIIU) "lhldelgrmnul Slnrnge TAnk Dlspositnn '1'rncking Record", except 111036 requiring a
<br /> slguntnre null dale of tank tcmoval. 'the holder of the petndt shall be tesponsibie rot ensuring that
<br /> this form Is compicied and returned Io ri IS-EI ID within 30 days of the lank removal.
<br /> I+� 1. 5111111111 n "Site r1en1111 A Surely Plan" ns no addendum It, this applicallon, to address nil polenlild
<br /> lutmlls fill 11113 specific lob 511C. Refer 10 1he Site Safely plan Ouldance Document for Specifics.
<br /> If facility Is located ou,slde of theIllyIlnds, a "IlackBllrXcaretlan Celliticnte" as tequliedby file CiOnfy oilSan rOAquln Uullding Deparineal and the Incorporated City Building Departments,a�n-
<br /> putsunnl to the Uniform 1311ildhlg Code S'lD 7,1-11.
<br /> I� 9. obtain n "(:rnd,ng nod Excnvalloo I'erndt" houf the City ourincy Building Division prior to PIIS- I!
<br /> I EI II) approval of the ciosulc plan.
<br /> III. •lite ninxlnllin review lime fir Closure Plans is 15 working days from receipt of the adequately
<br /> cnntpleted plan. If gross deliclencles Arc Idenfilled,nn nddendam will be required with a 578.00oor
<br /> fee nod the revlew will begin on the dale of rcaubndllnl.
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<br /> I ( Subndl vetilicafion of the Bre petndl front the appropriate Bre district at the removal Inspection.
<br /> 12. Advance 111 1) ion nonce of al lend 48 hours Is required by.pliSIHit).
<br /> 1-1123 (1117 (Revised I I/IN2) Page I
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<br /> A I)MAnn nl Son 1eAgnln Cnungy 11,01h Cot,Su.lc,x
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