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TO 19098651244 P 012 VWTS PUB SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst M.D. NI.P.H., Health Officer .cg4Ji�oRr'': 304 'Fast 'Weber Avenue, Third Floor • Stockton, CA 95202 2091468-3420 APPLICATION FOR PERMIT TO CLOSE ,I UNT) NKS STORING HAZARDOUS MATERIALS I., GENERAL INSTRUCTIONS. 1 Submit all information in triplicate. Answer ail questions, leaving no blanks. One copy will be. returned to the applicant with comments. j [ 2. Include a detailed site map on a separate sheet of paper, showing the location of the maks(s), piping, streets,adjacent properties(north toward the top of the page), nearby septic tanks, leachtields,water wells, buildings, underground public utility lines(including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included on the site map, you must state in writing that USA trig will be contacted prior to excavation activities. E 3 Complete page 3. 'Application for Underground Storage Tank Closure Permit". 'F 4. Complete page 9. "Authorization to Release". This form roust be signed and dared by the OVY ERIOPERATOR of the facility. [ 5. Submit the appropriate fees and complete page 11, cite "Underground Storage Tank Program Fee Worksheet". [ 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division(PHS-EHD) "Underbround Storage Taal; Disposition Trucking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD within 30 days of the tank removal. 1 7: Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. 8: If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments. pursuant to the Uniform Building Code STD 70-11. [ 9. Obtain a "Grading and Excavation Pen-nit" from the City of Tracy Building Division prior to PHS- EHD approval of the closure plan. 10. The maximum review time for Closure Plans is 15 worsting days from receipt of the adequately ` completed plant. If gross deficitncies are identified,an addendum will be required with a$78.00/hour fee iand the review will begin on the date of resubmittal. 11. Subunit verification of the fire permit from the appropriate fire district at the removal inspection. ti 1-y, Advance inspection notice of at least 48 Bouts is required by PHS-EHD. E4 23 046 (Revised 9/11/76) Page I i i I A Division of San joaquin County Health Care Services