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C�HEALTH SERVICES <br /> PUBLIC <br /> SAN JOAQUIN COUNTY = a <br /> Y_ I_TIIit <br /> ENVII(ONMC;N'I'AL IILAL771 DIVISION <br /> Is'l- nest M. Frijirnoto, M.D., M.l'.11., Acting ileahll Officer <br /> p y <br /> r - q� Lf .rya• <br /> I 4445 AYSau Joaquin Street " 1'. O. Box 388 " Slocklon, CA 95201-0388 PAY T <br /> 2119/468-3420 RECEIVED <br /> AI'1'I,ICA'l'IUN FOR I'ISRhII'1"1"U CLUSi MAR 19 1996 <br /> UNllISRGROUND 5TURAGI6'11ANKS STORING IIAZARUUUS MA'JERJALSSAN JOP%wN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> OENERAL INSTRUCTIONS: ENVIRONMENTAL HEALTH DIVISION <br /> I� 1. Submit nil Inforundon In triplicale. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> I 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s), piping, <br /> streets,adjacent properlie5 (north toward the top of the page), nearby septic tanks, leachfields,water <br /> wells, buildings, underground public utility lines (including water, snnitary sewer and storm sewer), <br /> and distance of piping from lank to dispensers. If underground utilities are not included on the site <br /> map, you muss state In willing that USA Dig will be contacted prior to excavation activities- <br /> W/ 3. Complete page 3, 'Applicrdlon for Underground Tank Closure Permit". <br /> IgI J. Complete page 9, "Authoriza(ion to Release Annlylical Dnln". This form must be signed and dated <br /> by the O1VNflt/01'fi1tATOR of the facility. <br /> 5. Submit the npp oijulate fees and complete page 11, the"Underground Tank Program Fee Worksheet". <br /> . . / 0Wn4w 61�_� Ig1?6 of6/ 70 <br /> K4' 6. Complete nil questions on page 10, One Public llealth Services-Environmental Flealth Division <br /> (PIIS-EI ID) 'Underground Storage Tank Ulspositlou Tracking Record", except those requiring a <br /> signature and date or lank removal. 'The holder of the permit shall be responsible for ensuring that <br /> this form is completed and icturned to Pi IS-El ID within 30 days of the tank removal. <br /> I 7. Sobnnil n 'Site Ilenlnn Ar Safely I'Inn" as an addendum to this application, to address all potential <br /> ha7atds for Ods specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> 8. If facility Is located outside of file city limits, submit a 'Backnll fixcnvation Certincnle" as required <br /> by the County of San Jonquin Building Department and the Incorporated City Building Departments, <br /> pursuant to the Uniform Building Code S'Ib 70-11. CovZ;6aQ5 <br /> / rM 9. Obtain a Y:rndlmg and Excnvminii Permit" from Ole City of Tracy Building Division prior to PHS- <br /> EI;D approval of (lie closure plan. <br /> The maximum review little for Closure Plans is 15 working days from receipt of the adequately <br /> compieled plan. If gross deficiencies are Identified,an addendum will be required with a S78.00/Itour <br /> fee And Tile teview w111 begin oil lire (late of mubndllAL <br /> Submit verification of the fire permit from the appropriate fire district at the removal Inspection, <br /> 12. Advance Inspection notice of all least 48 hours Is required by PHS-1111D, <br /> EII 231817 (Revised Il/l/92) Page I <br /> A mvistnn or Sen Joaquin CoanryY nedlh Cue Service' <br />