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PUBL-; HEALTH SERIIIU) <br />SAN JOAQUIN G(IUNTY ° <br />J(x;l KHANNA M.D., M.P.II. <br />IlcalthOfficer <br />P.U. Box RHY) ( 1001 East III AVCIIIiC) Stockton, falifornia 95201 �( �LJ <br />(209) 4 6 9-3 4(111 <br />APPLICATION FUJI PERM10CLOSE <br />UNDERGROUND SI'ORA(:1 'TANKS STORING HAZARDOUS MA'1'LIt1A1 S <br />GENERAL INSTRUCTIONS: <br />L Submit all infolIna loll in triplicate. One copy is returned to the applicant with comments. showing tank location and type, piping, <br />( 2. Include a detailed site map, on a separate sheet of paper, ' <br />page), location of the nearby septic tanks, <br />streets and adjacent properties (north toward Ute top of the <br />Icachriclds, wells, building%, underground public utility lines (including water, sanitary sewer and storm <br />sewer), ;fail dislance of piping from tank tD dispensers. <br />3. Complete page 3, "Applicnifou for Underground Tnnk Closure Permit". <br />4. Complete page 9, "Aathorizalion to Itelcnse Analytical untn". <br />5. Submit the appropriale fees and complete page 11, the "Underground'1'mhk Program Fee Worksheet". <br />ri. Describe on pages 4 & 5 fine decontamioatfoo techniques if applicable, material(s) utilized for rinsate, <br />vanspurmton and)or storage of harxrdous waste generated un site, and specify the responsible <br />parly(les) who will be disposing of waste generated on site. <br />7. Describe on page 5 the method for purging andlor inerting lank(s) and piping. <br />R, Describe on page 5 in dcblil how Soil and/or water salnplas beneath the tank(s) and piping will be <br />obtained. <br />9. Complete fine petlincal section of page 10, (lie Public Health Services -Environmental Health Division <br />(PIIS -EI ID) "Underground Took Dispositiou Trucking Itecord". The holder of the permit shall be <br />responsible for ensuring tint tills form is completed and returned to PHS-EUID. <br />to. Submit a "Site llcolth R Solely pian", as an addendum to this application, to address all potential <br />hazards for this %pecilic )ob site. Refer to Site Safety Plan Guidance Document for specifics. <br />I I• ihfa11tgDepartments, required Joaquin <br />Building <br />iinDand <br />tsincorIra edCy Building pursuant to the Uniform Building STD 70-1 <br />12. obtain a "Grmling and I'XcAvillhol Perndt" final the City of Tracy Building Division prior to PHS - <br />EI ID approval of the closure plan. <br />lans is 15 <br />ng days <br />eipt or <br />ile <br />ely <br />13. co iplel idlplanrelf grusshdeficieneies ate osure 'fdcnUfied, an addendum willtbeertre1 lie maxum quired iredwith a $53.00/hour <br />ice and the review will begin on the date of resubmittal. <br />14. Submit verilicilfon of the fire permit from Ibe appropriate fire district (prior to scheduling removal <br />Inspection). <br />I I IS. Advance los lection notice of at least 4g Mom's is re uired by Public I Iealth Services. <br />Page I <br />A Division nr San Joaquin Cnnnty Health Care Services <br />