REMOVAL_1996 - Laserfiche WebLink

Home Browse Search

PUBLID HEAL 1 H 01-A\ �IL1-JS .� SAIN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Ernest M. Fujimoto, M.D., M.P.H., Acting, Health Officer 445 N. San Joaquin Street • P. 0. Bos 388 • Stockton. CA 95201-0388 209/468-3420 t tLLLG APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS GENERAL INSTRUCTIONS: Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. No 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, leachfields, 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. a (y]' 3. Complete page 3, 'Application for Underground Tank Closure Permit'. ( 4. Complete page 9, "Authorization to Release .Analytical Dam'. This form must be signed and dated by the OWNEXOPERATOR of the f_ac�il�irv. �T /1 Te S-c� C 6r u ') cow - J°"�'"""' �.a.•n C:n�t �G�uin� p til c� �. Submit the�aPpropria[e fees and complete page Il, c e'Underground Tank Program Fee Worksheet". (] l3ftG/C t CZO �jI/2 6o "Z2 T4, // 6) 6. Complete all questions on page 10, the Public Health Services -Environmental Health Division (PHS-EHD) 'Underground Storage Tank Disposition Tracking Record", except chose 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 t0 PHS- ID within 30 dans of the tank removal. 7. Submit a 'Site Health 8: 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 loaned outside of the city limits, subunit 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. to o f elf b lftl vz`��/�`� 9. Obtain a *Grading and Excavation Permit" from the City of Tracy Building Division prior to ?H1Sy-"— EHD approval of the closure plan. 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 578.00/hour fee and the review will begin on the date of resubmittal. Submit verification of the fire permit from the appropriate fire district at the removal inspection. (] 1? Advance insoecrion notice of at least 43 hours is required by pHS-EHD. i:H 23 007 (Revised 1111/92) Page 1 A Division of Sun Joaquin County HnLLh Care Services