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PU3LIC HEALTH SERVICES <br /> SAN JO.,kQT--LN C0UNT1 <br /> ENVIRONMEtiTAL HEALTH DIVISION <br /> Karen Fit-at, M.D., 143.P.H., Health Officer <br /> .Ou <br /> 504 East Weber Avenue, Third FIoor • Stockton, CA 95202 <br /> 209/368-3420 <br /> APPLICATIO% FOR PE nr TO eLOSE <br /> ( vDFR^ROt'YD CYORAGE TA\'Ke 970RLiG 142=O1tSyL4,TERIALS <br /> i. GENERAL INSTRUCTIONS: <br /> 1. 5abmit a!1 mfor...ariea in triplicate. Aasm•er all questions, leaiing no blinks. Oce copy will be returned <br /> to the applicant with ccameres. <br /> r I Include a detail-ed site trap on a separate sheet of Pape:, show'itta the '.ecation of the tacks(spiping, <br /> strees, adjacent properties (north toward the top of the page), nearby septic tanks, leachlelds, water <br /> wells, buildings, undergrouad public utility lines rhedpding w;,er, sanitary sewer and storm sewn), and <br /> distance of Piping from tank to dispensers. if underiroLad utilities are not ncluded on a site atP, you <br /> must sou in wrdng that USA Zig will be comacrEd prier to excavatier.ac iv ties, <br /> T j 3. Complete page 3, *Application for Underground Storage Tack Closure Permit". \tot:: San:.^.ling <br /> firm snail be an ittd=eadent third pary from the contrzc= <br /> i 1 Complete page 5 "Authorization to Relessa-. T'.tis fcr= =ust Se signed and dated b•; :he <br /> Ott N MOPERATOR of the facility <br /> Submit the appropriatc fees and complete page 11, the 'Undarround Storage Tank Program Fee <br /> Work ben". <br /> j 6. Complete ail questions ern page I0, the Aiblic Staph Services-Eavrenmantal Health Division (Yr.5• <br /> EHD) "Underground Storage Tank Disposition Tracking Record", exceot LLse requiring a signature <br /> and date of tat:t, ,er.oval. The holder of:he permit shall be rdponsibie for crsurirg that this for is <br /> coc:pleted and returned:o PHS•EHD within 30 days of the tar_'<:etrovai. <br /> Submit a "Site Health & Safety Plan" as ar, addendum to this application, to address all Potent a; <br /> hazards for:his speciac job site. Rafe,,w the Site Sai ty?Ian Gu:datta Document for specifics. <br /> I S. If facility is located ouaide of the cay limits, submit a 'Backfill Excavation Certiticate" as required b;+ <br /> the County of San :eaquin Building DePa mem arta ,he incorporated City Building Deper=cats. <br /> pursuant to the Uttiform Suiidirg Code STD 70-1 i <br /> ( 1 9 Obtain a "Grading and Excavation Permit" =om Lie Cir; of Tracy Building Division pr-or to PHS- <br /> ,14D approval of the eicsure plat <br /> the max.mure review :hue for Closure Pians is 15 working days from nx:tp: of the adequately <br /> cemplcted plan. If ylrast defcietteies are iderafed, an addendss <br /> n will be required with a S 8.0),% <br /> fee mad:he review will betia ea the dare of resubmiaal. <br /> Submit verfcaticn of the fire permit f:o:n Cie appropriate lire distrcr at t�.e rem-n-4 inspection. <br /> [] 1?, t vanee iso i r tet 'at leas~��^„r• . =tdred Sv P1»5-E•r.7 <br /> r j 13_ Submit Cortiagency?len for over-excaca:ios u time of UST removal (if planning:o overexcavate). <br /> See "III. SITE"AlTIGATI0%— on pace <br /> EH '_3 046 iRevised 08lI3l49) Page 1 <br /> A Cntrien d Sar.Ioagain Cauar/Hasid:Can Se icee <br />