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PUBLIC HEALTH SERVICES ,p44�IN <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION m :e <br /> Ernest J. Fujimoto,M.D., M.P.H.,Acting Health Officer <br /> 445 N. San Joaquin Street •P.O.Box 388 • Stockton,California 95201 • �., �y. <br /> (209) 468-3420 '9ttFoad <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> [ ] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> [ ] 2. Include a detailed site map on a separate sheet of paper, showing the location of the tank(s), piping, <br /> streets, adjacent properties (north toward the top 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 state 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 /> [ ] 5. Submit the appropriate fees and complete page 11, the "Underground Tank Program Fee <br /> Worksheet." <br /> [ ] 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS- <br /> EHD) "Underground Storage Tank Disposition Tracking Record," except those requiring a <br /> signature and date of tank 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 tank removal. <br /> [ ] 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential <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 Certificate" 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 plan. <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 date of resubmittal. <br /> [ ] 11. 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 /> EH 23 007 (Revised 01/02/95) Page 1 jBAa <br /> NO Pffi'r.Water 'Iue. <br /> I7Ji, Ia29W. Fremont St. <br /> 1TY; S€ock€on, CA 95203 <br /> A Division or San.loaquin County Health Care Services <br />