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PUBLk`116 HEALTH SER;ICES <br />a � <br />SAN JOAQUIN MUNTY / • i< <br />JMI KHANNA M.R. NI -I'll. A :< <br />IWith 011ircr e��l dalp•' <br />I'.U. Dox 2009 (I(d)I Gast Ilazehon Avenue) Stucktun, California 95201 <br />(209) 468 - 3400 <br />APPLICATION FOR Phl"'I' TU CLOSE <br />UNI)FAIG1(OUND STORAGK TANKS STOKING HALARDOUS MA'1'I?111ALS <br />UENERAL INSTRUCTIONS: <br />I I 1. Submit nil information in triplicate. One copy Is returned to the applicant with comments. <br />I 2. Include a detailed site map, on a separale sheet of paper, shuwing tank location and type, piping, <br />streets and adjacent properties (numb coward rhe lop of the page), location of lite nearby septic ranks, <br />Icachlichis, wells, buildings, underground public utility line -%(including water, sanitary sewer and sloinn <br />sewer , and distance of piping butt lank to dispensers. <br />1. Complete page 3, "Application for Uodergronnd'Untilt Closure Permit". <br />I 4. Conuplcle page 9, "Aufhorizntion to I(elense Aonlyllcnl untn". <br />I 5. Submit tire- approp, late fees and complete page 11, the "Underground'1'mik Program pee Worksheet". <br />I I 6. Describe on pages 4 & 5 the deconial %,cot, technique-% If applicable, lnalerfal(s) utilized for Fit Sate, <br />hansportalion and/or slofilge of hazardous waste generated uu site, and specify the responsible <br />pally(les) who will he dislimiag of waste generated on site. <br />I 7. DeSCtibe on page 5 file method for purging and/or incring tank(s) and piping. <br />I <br />H. Dcscrihc on page 5 In dclail how soil andfnr wader samples hcncath lite lank(s) and piping will be <br />obtained. <br />I 9. Congnletc file pertinent section of page II)the fabric I lealtin Services-L^nviromuenlal I lealdr Dlvislon <br />(1'I IS -1:111)) "Underground Tank Disposition'1'Inckbig Record". 'I'hc holder of the permit shall be <br />resppnsiblc for ensuring that this form is completed and returned to 1'l IS -EMD. <br />Ill. Submit it "Site liwlrh & Safely 1'11111", as am addendum to Ibis application, to address all potential <br />R <br />hazards lirr this spccilic jab site. efer III Site Safety Plan Guidance Document for sperafIcs. <br />Ile <br />in <br />t and <br />11. II,s�ili rmit rpondcd aCity building Departments,lypursuant County <br />file Uuibtrn BuildingbnCode 51D 70-1. <br />,xcnvntion l'crnalt" front the City of Tracy Building Division prior to I'lIS- <br />12. Obtain n '0114111T anti tEl ll) approval of tine closure plan. <br />I). '1 lie nrexinmmlr review lime for Closure 1'11rns IS 15 working days from receipt of the adequately <br />completed plan. If gross deficiencies arc identified, air addendum will be required with a SSJ.ODArour <br />fee find Ilio review will begin on the date of re-%ubntiftal. <br />14. Submit verification of the lire permit (roan the appropriate (ire district (prior to scheduling removal <br />inspection). <br />I 15. Advance insPectiun notice of nl lenst 48 hours is required by Public Health Services. <br />Page I <br />A 1*10nn nr Sen Janquin enemy tleal,h Care Strutter <br />