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oA4� N San Joaquin County Environmental Health Department DIRECTOR 1868 E. Hazelton Avenue Donna Heran,REHS Stockton, California 95205-6232 PROGRAM COORDINATORS c' P Robert McClellon,REHS Website: www.sjgov.org/ehd Jeff Carruesco,REHS,RDI Phone: (209)468-3420 Kasey Foley,REHS F 209 464-3433 Linda Turkalte,REHS Fax: ( ) Rodney Estrada,REHS Adrienne Ellsaesser,REHS APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT I. GENERAL INSTRUCTIONS: [] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. [] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included on the site map, you must state in writing that USA Dig will be contacted prior to excavation activities. [] 3. Complete pages 3-5, "Application for Underground Storage Tank Closure Permit". Not : Sampling firm shall be an independent third party from the contractor. (] 4. Complete page 8, "Authorization to Release". This form must be signed and dated by the OWNERIOPERATOR of the facility. [] 5. Submit a"Service Request"form with the appropriate fees, submit completed UPC forms for Facility and Tanks (formerly State A& B forms)and complete the"Underground Storage Tank Program Fee Worksheet". [] 6. Complete all questions on page 9, the Environmental Health Department (EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to EHD within 30 days of the tank removal. [] 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. [] 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-11. [] 9. Obtain a"Grading and Excavation Permit"from the City of Tracy Building Division prior to the Environmental Health Department(EHD) approval of the closure plan. [] 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a$130.00/hour fee and the review will begin on the date of resubmittal. [] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. [] 12. Advance inspection notice of at least 48 hours is required by EHD. [] 13. If planning to over-excavate at time of UST removal, see"III. SITE MITIGATION"on Page 2. EH 23 046 (Revised 07/17/14) ]