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PUBI ITC HEALTH SLA tE§' SAN JOAQUIN COUNTY � fl J JOGI KHANNA M.D.. M.P.H. ' I Health Officer P.O. iioa 2009 • (1601 Flu HvrJtan Avenue) • Stocinon, California LaU (209)`!68-3400 JUL 0 7 1992 APPLICATION FOR PERMIT TO CLOSE CA GENERAL INSTRUCTIONS: ' -x1111 `�'LWCES [ ] i. Submit all information in triplicate. One copy is returned to the applicant with comments. f 1 2. Include a detailed site mar). on a cenarnte Sherr of paper, showing •gr^ anntf— ar, l � le, nin;rg streets and adjacent properties (north toward the top of the page), location of the nearby septic tanks, leachfieids, wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. [ ] 3. Complete page 3, 'Application for Underground Tank Closure Permit'. [ ] 4. Complete page 9, 'Authorization to Release Analytical Data'. (] 5. Submit the appropriate fees and complete page 11, the'Underground Tank Program Fee Worksheet'. [ ] 6. Describe on pages 4 & 5 the decontamination techniques if applicable, material(s) utilized for rinsate, transportation and/or storage of hazardous waste generated on site, and specify the responsible party(ies) who will be disposing of waste generated on site. [ ] 7. Describe on page 5 the method for purging and/or inerting tank(s) and piping. [ ] 3. Describe on page 5 in detail how soil and/or water samples beneath the tank(s) and piping will be obtained [ ] 9. Complete the pertinent section of page 10, the Public Health Services-Enviroamental Health Division (PHS-EHD) "Underground Tank Disposition Tracking Record'. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD. [ ] 10. Submit a 'Site Health & Safety Plan', as an addendum to this application, to address all potential hazards for this specific job site. Refer to Site Safety Plan Guidance Document for specifita. [ J I1. Submit a 'Compaction Report' as required by the County of San Joaquin Building Department and it's incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1. [ ] 12. Obtain a "Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- EHD approval of the closure plan. [ ] 13. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a S53.001hour fee and the review will begin on the date of resubmittal. [ 1 14. Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal inspection). [ 1 15. Advance inspection notice of at least 48 hours is required by Public Health Services EH23-007 (1/10/92) PAGE 1 A Durston of San Joa um loun� He o C rc _ n,cm 0