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JUN 6 2000 PUBLIC HEALTH SERV ICESENVIPR ONE r 'SETH SA-N SOAQUL COUNTY / e,\ EWIROIrMENYTAL HEALTH d?ItiISIOn [; Karen Fust, NI.D., 3A.P.H., Health Officer �. 304 East Weber Avenue, Third Floor • Stockton, CA 95202 209/168-3420 AppLicATio-vBog PF?NnT TO CLOSE C�1DERGROVXD STORAGE TA.\7t5T0RI;G HA2.ARDOLS NLATEP.IALS I. GENERAL INSTRUCTIONS: 1. Submit a!, infor narioe is triplicate. Answer ail questions, leaving no blanks. One coon 'x11 be rrurned to the app:icant with ccamencs. '_. include a detailed site a:an on a separate sheet of paper, slowing the location of the utaks(s;, piping, ,tree:;, adjacent properties (north toward the lop of the page), nearb;, septic tanks, leachfields, water wells, buildings, underground public utility linea rmending water, s27.ltary sewrr and storm sewer), and distance of piping frog tank to dispemers. if;m.Cargrouad utilities ar:tet included on the site map, ,you must state m wrtltfg that us k%ig will be comac.:d prior:o eicavw.ion.actin ties. T/ 3. Complete page 3, "Application for Underground Storage Taak Closure Permit". ,foto: Samplina f,m shall be an independent third oary from the coatrec—�r. i ;. Complete page S, "authorization to Release'. This form mast be signed and dated I:y the OwvERlOPERATOR of the facil:ty 5. Submit ffic approprizr fee and ampiete page 11 the,/"Underground Storage Tank Program Fee ' / works-belt". .S. i &111 ZQ� ba,-, e � "'�� , ty/ 6. Complete ail questions on page 10, the P•iolic Health Seervt^.as-En%rircnntental Health Division (PFS- EHD) "Underground Storage Tank Disposition Tracking Record", except rbcs requiting a signature and date of tarU removal. The holder of;he permit sh&l 1 be responsible for c.--suring that this form is completed and returned:o P115•EHD within 30 days of the tank removal. [ 7. Surma a "Site Health & Safety Plan" as at, addendum to this application. to address all potential hazards for:his specs c job sate. Refer w the Site Safety ?Ian Guidancz Document for specifcs. [�s, if facility is Srxmed ou-side of the city limits, subirit a ,%ackruii Excavation Certificate" as required by the Cotmty of San Jcaquin Building Departin and the incorporated City Building Depar=cns. pursuant to the Utriform Building Code STD 70-1 . 9 Obtain a "Grading and Excavation Permit" from the Ciry a: Tracy Building Division prior to PIKS- EHD approval of Se closure plain. lbe maximum review :am: for Clov;re Plans is 15 Work ng days from receipt of the adequately' comXicted plan. If gross deEcienc:es ate identified, an addendum pili be required with a Si8.00,ho= fee and:he review will bema or uhe bate of resubmittal. Submit Yenfcatirn ot'the fire persit fror the appropriate lire distrct a:t:a roe x, al$rspecdoa. g 4 -B:gdVanCe in;De"ion fiCCCe Of a leos-, 'A itoui rn � rL[ed by P.-$ .. r] 13. Suba it Contingency?Ian for ovet-e;cavo a at rice of UST removal (if planning to overtxcavate). See "III. SITE:41-115ATION— ne Page 2. EH ;G46 iRevised 0813.'99'1 Page 1 A OMAIen o!Sae.^.jCacula Cou.^.:!Heai!h Cage Se-,ice!