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PUBLIC HEALTH SERVICES - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION. ' Karen Furst, M.D., M.P.H., Health Officer qr cf;:os• 304 East Weber Avenue, Third Floor Stockton, CA 95202 209/468-3420 ' APPLICATION FOR PERyIITTO CLOSE. L"-DERGROUND STORa.GE TANKS STORDiG H-AZAIMo US V1aTEffia.LS I. GENERAL INSTRUCTIONS: Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be retuned to the applicant with comments. ,[] ^_. 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 thepage), nearby septic tanks, leaclrfields, water t wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distant: of piping from tank to dispensers. If underground utilities are not ncluded on the site map, you must state in writing that USA Dig will be contacted prior to excavation activities. '[] 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". tae: Sampling firm shall be an indeoe-tdenc third cam from tine contractor. ,[ ] 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the OWNER/OPERATOR of the facility. [ ] 9. Submit the appropr ate fees and complete page 11, the "Underground Storage Tank Program Fee ' Worksheet". [] Public Health Services-Environmental Health Division (PHS 6. Complete all questions on pale 10, he. - ' 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 s completed and returned to PHS-EHD within 30 days of the tank removal. 'I ] 7, Submit a"Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer co the Site Safety Plan Guidance Document for specifics. ,[] 8. If facility is located outside of the city limits, submit a "Backfill Excavarion Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to r he Uniform Building Code STD 70-11. ,(j 9. Obtain a "Grading and Excavation Permit" tom the City of Tracy BLLil ding Division prior to PHS-E, approval of the closure plan. '[ ] 10. Tee maxunum 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 wi[h a S87.Cd/hour fee and the review will begin on the date of resubmittal. [] !1 Submit verification of the fre permit from the appropriate fire district at the removal inspection- ] 12. Advance inspection notice of at least 43 hours is reouired by PHS-EHD. 13. Submit Contingency Plan for over-excavation at time of CST removal ('If planning to aver-excavate). [] See 'III. SITE MITIGATION" on Page'-). ' Page 1 EH 23 046 (Revised 09/21100)