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r PUBLIC-HEALTH SEMxI,.ES ' ;` ` <br /> SAN JOAQUIN COUNTY =' <br /> c 4 <br /> e; I <br /> )OGI KHANNA M.D,M.P.H. <br /> Health 011icci <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) a Stockton, California 95201 cell i+dA�� <br /> (209) 46&3400 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUG"HONS: <br /> [ ) I. Submit all Information In triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> [ 1 2. Include a detailed site map on a separate sheet of paper,showing the location of the lanks(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 lank to dispensers. If underground utilities are not Included on the site <br /> map, you must stale in writing that USA Dig will be contacted prior to excavation activities. <br /> [ 1 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> [ 1 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 /> f1 5. Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet <br /> i <br /> [ 1 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 /> 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 PNS-EHD within 30 days of the lank removal. <br /> 1 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 /> 1 8. If facility Is located outside of the city limits, submit a 'Back011 Excavation CertiBcale' 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 /> [ J 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 /> [ 1 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 /> [ [ I1. Submit verilicallon of the fire permit from the appropriate fire district at the removal inspection. <br /> [ 1 12. Advance inspection notice of at least 48 hours is required by PMS-EMD. <br /> i <br /> EH 23 007 (Revised 11/1/92) Page I <br /> A DMblon of Sm Joayuln CountyIleilth(:arc SeMen <br />