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08l12/2002 13:14 2ti94533433 FIFTH FL" PGE 02 <br /> ENVIRONMENTAL WALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY unitApervisors <br /> }4A4M,')rr <br /> D*""K_aeras,lt.P..a.s. F-ast Wcr ber Avenue,Third Flow cart soman,R.ESis. <br /> 304 <br /> w;. Director Mike Huggins,RE.H.S.,R.D1. <br /> Al odsea,R.E.H.S. Stockton, California 95202-2708 Douglas W.wllsoo,lLE.H.s. <br /> Pirigra Manager Telephone: (209) 468-3420 MargarctLagorio,R.E.H.S. <br /> q�iebF" Laurie A.Cotalla,FLE.B:S. l7Rx; ( �}464-013g <br /> Robert McClelloo,R.S.H.S. <br /> progmrm mancee' Mark$aicdi8s,R.E.H.S. <br /> APPLICA110N FOR PERMIT TOC SE <br /> U.NDERGROUNDSTOX&GE TANKS ST RKNG F A2ARDOUS MA TI RIALS <br /> I. GENERAL INSTRUCTIONS; <br /> Submit all information in triplicate. Answer all questions,leaving no blanks. Ons copy will be returned to <br /> The applicant with cor - <br /> Include a detailed site map on.a separate sheet of paper,slwwin3 the location of the tauks(a),Piping,streets, <br /> adjacent properties (north toward the top of the page), nearby septic etmks, leachfields, water wells, <br /> buildings,underground public utility iiztes(including water,sanitary sewer and storm sewer) and distance <br /> of piping from tank to dispensers. If underground utilities are not included on the site map,you I ase state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> [] 3. Complete page 3, "Applicattoa for Undargroumd Sterane Tank Closure Permit Ko saw;^o frrnr <br /> shall be an' ndent third part-$ern the conttaotor. <br /> 1] 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> [] 5. Submit a"Service Request'form with the appropriate fees, babacompleted UPC form for'Facility and <br /> Tanks (formerly State A&B forms) and complete page 11, the "Underground Storage Tank Program <br /> Fee Worksheet". <br /> () 6. Complete all questions on page 10,the Environmental Ilealth Department(HHD) ` LTndsrgr9"4 Storage <br /> Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The <br /> holder of the permit shall be responsible for auguring that this form is ramplatZd and rettaned to END <br /> within 30 days of the tank removal. <br /> (] 7. Submit a"Site Health&Safety Plan" as an addendum to this application,to address All potential hazards <br /> for this specific job site. Refer to the Site Safety Plum Guidance Document fur specifics. <br /> [] <br /> S. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by <br /> the County of San Joaquin Building Departmemt and the incorporated City Building Departments,pursuant <br /> to the Uniform Building Code STD 70-11. <br /> [] 9. Obtaiu a "Grading and EYeavation Permit" from the City of Tracy Building Division prior to EHD <br /> approval of the closure plan. <br /> [] 10- The*m&ximum review time for Closure Plans is 15 working days from receipt of the adequately completed <br /> plan. If gross deficiencies are identified, an addendum will be required with a $54.00/hour fee and the <br /> review will begin on the date of resubmittal. <br /> (j 1 L Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [] 12 ea�ig%F:G am notice of at least 48 hours is required by EFS <br /> [] 13 Submit Contingcocy plan for over-excavation at h=of UST removal(if planning to over-excavate). <br /> Sue"III. SITE MITIGATION"on Page 2. <br /> EH 23 046 (Revised 3/1S/02) Page I <br />