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V,I UJ. L�.+v Vim• L! LUU�V VJ-.JJ 1 11 i LVVI\ <br />ORIGINAL <br />PUBLIC HTALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION E <br />Karen Furst, M.D., MX.11- health Officer �� "-- R <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />APR i4l wUU <br />1"1VL UL <br />ENVIRONMENTf%L HEALTH <br />AP ICATION FOR PERMIT TO CLOSEPERMT / SERVICES <br />I. <br />GENERAL INSTRUCTIONS: <br />I.� <br />Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br />to dile applicant With eommenM. !il-m,2,o& c r , x <br />[� 2. <br />Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br />streets, adjacent properties (northtoward the top of the page), nearby septic tanks, leachfields, water <br />wells, buildings, underground public utliry lines (including water, sanitary sewer and storm sewer), and <br />distance of piping from tank to dispensers. If underground utilities are not included on the site map, you <br />must state in writing that USA Dig will be contacted prior to excavation activities. <br />[� 3. <br />Complete page 3, "Application for Underground Storage Tank Closure Permit". of : Sampfin <br />firm shall be an indeoendent third narty from the contractor, <br />[� 4. <br />Complete page 9, "Authorization to Release". This form must be signed and dated by the <br />OWNER/OPERATOR of the facility. <br />[t� 5. <br />Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br />Worksheet'. <br />(N 6. <br />Complete all questions on page 10, the Public Iiealrh Services -Environmental Health Division (PHS- <br />EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br />and date of tank removal. The holder of die permit shall be responsible for ensurigg that this form is <br />completed and returned to PHS-EHD within 30 days of the tank removal. <br />/ <br />"Site <br />[v� 7. <br />Submit a Health & Safety Plan" as an addendum m this application, to address all potential <br />hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br />[vK S. <br />If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by <br />the County of San Joaquin Building Department and the incorporated City Building Departments, <br />pursuant to the Uniform Building Code STD 70-11. <br />( ]N!p 9. <br />Obtain a "Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br />EHD approval of the closure plan. <br />[a- 10. <br />The maximarri review time for Closure Plans is 15 working days from receipt of the adequately <br />completed plan. If gross deficiencies are identified, an addendum will be required with a $78.00/hour <br />fee and The review will begin on the date of resubmittal. <br />[rl 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br />FIRL dhr.4 ,s <p pc<e iu p. -rliliol PvIe, a 4c0 c't p t%...7 ,,f. <br />(� 12. Advance inspection notice of at least 48 hours is reouired by DHS-EHD <br />Iii 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 08/13/99) Page 1 <br />A Division of San Joaquin County Health Care 5e ices <br />