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PUBLIC HEALTH SERVICES SAN JOAQUIN COUN-IT`! ENVIRONMENTAL HEALTH DIVISION. Karen Furst, M.D., M.P.H., Health Officer 4Z7Fo.�4.i SO4 East Weber Avenue, Third Floor • Stockton, CA 9.5202 2091468-3420 APPLICATION FOR MUNUT'TO CLOSE. UNDERGROUND STORAGE TANKS STORLNG HAZARDOUS "YIATERIALS 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. j 2. Include a detailed site map an a separate sheet of pager, showing tae location of frac 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 distane r, of piping from tank to dispensers. If underground utilities are not included on the site map, you must state in�::riting that USA Dig will be contacted prior to excavation activities. (� 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". of 4 Samptt firm shall be an independent third parry from the contractor. L lComplete page 9, "Authorization to Release". This form must be signed and dated by the 4. OWNERIOPER- TOR of the facility. j 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee Worksheet". l Complete all questions on page 10, the. Public Health Ser<nces-Environmental Health Divisicn (PHS- 6. 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 PHS-EHD within 30 days of the tank removal. 7, Submit a "Site Health & Safety Plan" as an addendum co 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. L 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD approval of the closure plan. ( j I0. T'n_z maximum review time for Closure Plans is 15 working days from receipt of the adequately completed pian, If gross deficiencies are identified, an addendum will be required with a 58-1.00/hour fee and the review will begin on the date of resubmittal. 1!. Submit vetzf cation of the fire permit from the appropriate tire district at the removal inspection. 1 12. Advance inspection notice of at least3 hours is rep�rired by PHS-EHD. 13. Submit Contingency Plan for over-excavation at time of UST removal (if planning to over excavate). See ;III. SITE MITIGATION" on Page 2. EH a 046 (Revised 09121!00) Pave 1 �es1t1 Care' ices