REMOVAL_1999 - Laserfiche WebLink

Home Browse Search

PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY -1 ENVIRONMENTAL HEALTH DIVISION k'_ .< Karen Furst, M.D.,M.PH- Health Officer 71 304 Easr Weber Avenue, Third Floor• Stockton, CA 95202 JUN 2 199 209/468-3420 ENVIRONMEN fA APPLICATION FOR PERKU TO CLOSE PERMIT/ SERVICtzS UNDERGROUND STORAGE TANKS STORING IIAZAA tWUS MAI-EFdALS I. GENERAL INSTRUCTIONS, 1. Submit all information in triplicate_ ,ever all questions, leaving no bUnks. One copy will be returned to the applicant with enmmeats. 2. Include a detailed site map on a separate sbect of paper, showing the location of the tanws). piping, streets, adjacent properties (notch toward the top of the page), nearby septic ranks, leachrieid3, water wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispenses. If trade-ground utilities are not included ori the site map, you / must state m wri=ng that USA Dig will be contacted prior to excavation acrivities. 1{� 3. Complete page 3, 'Application for Underground Storage Tans; CIosure Permit'. Nae. Sampling J firm shall be an independent:bird party from the contractor_ !�f 4. Complete page 9, 'Authorimtion to Release". This form must be signed and dared by the OWN 3UOPERATOR of the facility. 5. Submit the appropriate fees and complete page 11, the "Undergrouad Storage Tank Program Fee Worksheet". (� 6. Complete all questions on page 10, the Public Hesith Se,vices-Eavironmemai Health Division (PHS- EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signatwe and date of tank removal. The holder of the permit shall be responsible for ensur..g that this Corm is completed and returned to PHS-EIID within 30 days of the tank removal. 7. Submit a "Site Health & Safety Pian" as an addendum ro this application, to address all potential hazards for this specific job site. Refer m the Site Safety Plan Guidance Docuntent for specifics. Its 8. If facility is located outside of rite city limits. submit a "Backfill Excavation CerttMcare" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to die Uniform Building Code STD i0-I1_ w 9. Obtain a "Grading and Excavation Permit* from the City of Tracy Building Division prior to PHS- / EHD approval of the closure pian. [L) to. The ma;d= review time for Closmc Plans is 15 wodting days from receipt of the adequately completed pian. If gross deficiencies are idea=fied, an addendum will be required with a 578.00/hour / fee and die review will begin on the date of resubmittal. (13 It. Subunit verification of the fire permit fmm the appropriate 5re disuia ar the removal inspection. L'_ Advance vupection notice of at least 48 boars is rewired by PISS-EHI) EH 23 046 (Revised 10/19/98) Page I