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COP <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY s` <br /> a: 1 <br /> JOGI KHANNA M.D.,MY K <br /> Health Officeru <br /> • d•k <br /> P.O. Box 2009 a (1601 East Razelton Avenue) a Stockton, CaW'omla 95201 <br /> (209)468.3400 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MAI'ERTAIA <br /> GENERAL INSTRUCTIONS: <br /> ( ( L Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> ( J 2. Include a detailed site map on a separate sheet of paper,showing the location of the Ianks(s), piping, <br /> streets,adjacent properties (north toward the lop of the page), nearby septic tanks,leachfields,water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br /> and distance of piping from tank to dispensers. If underground utilities are not included on the site <br /> map, you must slate In writing that USA Dig will be contacted prior to excavation activities. <br /> ( ( 3. Complete page 3, 'Application for Underground Tank Closure Permit'. <br /> ( ( 4. Complete page 9, 'Authorization to Release Analytical Data'. This form must be signed and dated <br /> by the OWNER/OPERATOR of the facility. <br /> ( J 5. Submit the appropriate fees and complete page 11,the'Underground Tank Program Fee Worksheet'. <br /> ( ( 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division <br /> (PHS-EHD) 'Underground Storage Tank Disposition Tracking Record', except those requiring a <br /> i <br /> signature and date of lank removal. The holder of the permit shall be responsible for ensuring that <br /> this form Is completed and returned to PHS-EHD within 30 days of the lank removal. <br /> ( ( 7. Submit a 'Site health & Safely Plan' as an addendum to this application, to address all potential i <br /> hazards for this specific Job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> ( ( 8. If facility is located outside of the city limits, submit a 'Backfill Excavation Cerlincate' as required <br /> by the County of San Joaquin Building Department and the Incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11. <br /> ( ( 9. Obtain a 'Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure pian. <br /> ( ( 10. The maximum review time for Closure Plans Is 15 working days from receipt of the adequately <br /> completed plan. If gross deficiencies are Identified,an addendum will be required with a$78.00/hour <br /> fee and the review will begin on the dale of resubmittal. <br /> ( ( <br /> if. Submit verification of the fire permit from the appropriate fire district at the removal Inspection. <br /> ( ( 12. Advance Inspection notice of at least 48 hours Is required by PHS-EHD. <br /> i <br /> I <br /> EH 23 007 (Revised 11/1/92) Page 1 <br /> A DMtlm d San loaqutn Caunh Haalih Cve Scavlco - . .. <br /> _....._.__._................ , <br />