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PUBLIC HEALTH SERVICES ,oro <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION 3 < <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting Health Officer <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Stockton, CA 95201-03888 �izoa ' <br /> 209/468-3420Cv(.riQis'f <br /> APPLICATION FOR PERMrr TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. <br /> 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br /> streets, adiacent properties(north toward the top of the page), nearby septic tanks, leachfields, water wells, <br /> buildings, underground public utility lines(including water, sanitary sewer and storm sewer), and distance <br /> 1 of piping from tank to dispensers. If underground utilities are not included on the site map, you must state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> 3. Complete page 3, A 1i tion for Under round Stora a Tank Closure ermit". S�K/yV <br /> g, 4. Complete page 9, "Authorization to Release . This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. a e <br /> j -Yt-e 5 <br /> 5. Submit the appropriate fees and complete page 11, the "Under-round Storage Tank Program Fee <br /> Worksheet". - I / �V <br /> [� 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division(PHS-EHD) <br /> "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date <br /> of tank removal. The holder of the permit shall be responsible for ensuring that this forrn is completed <br /> and returned to PHS-EHD within 30 days of the tank removal. <br /> 7. 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 the Site Safety Plan Guidance Document for specifics. <br /> If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the incorporated C Building Departments, <br /> pursuant to the Uniform Bilding Code STD 70-11. _S j P t aA"&t� y X4^0 <br /> o� I� I VV or <br /> 9. OLit a "Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure pian. <br /> j� 10. The maximum 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 573.00/hour fee <br /> and the review will oegin on the date of resubmittal. <br /> {� 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> 1_. Advance inspection notice of at least 43 hours is required by PHS-EHD. <br /> .3 0416 (Revised 9/11/96) Page 1 <br /> A Dix islor.o:S_r.'o.�y:.:r.Cit nn Hea,:i Cart 4rr.;1c4< <br />