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PUBLIC :'HEA ` '1UEN <br /> LTH <br /> _.. >.•�:•..off <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION a: <br /> ' Ernest M Fujimoto," Acting M.P.H., Acting Health Officer <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 9 Stockton, CA 95201-0388 "iii cps` <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> ruSTORAGE TANKS ORM 'oZARD US MATER?ATS <br /> L7NDERGROin <br /> GENERAL INSTRUCTIONS: <br /> questions,leaving no blanks. One copy will be returned <br /> ] 1. Submit all information mtriplicate Answer all <br /> to the applicant with comments. <br /> I� 2, Include a detailed site map on a separate sheet of paper, sbowing the location of the tanks(st piping, <br /> 41 ,9� streets, adjacent properties(north toward the top of the page),nearby sepsewer tanks, <br /> ks, seweleachfielr),and distance <br /> buildings,underground public utility lines(Including water, sanitary you must state <br /> ��(L of piping from tank to dispensers. If underground utilities are not included on the site map,y <br /> in writing that USA Dig will be contacted prior to excavation activities- <br /> 3. . Complete <br /> ctivities... Complete page 3, Application for Underground Tank Closure Permit". <br /> N Ce cQ s l�a�x r�c� mR `a S� <br /> [] 4, Complete page 9 Authonz2tion to Release Analytical Data': This form must be signed and dated by <br /> the OWNER/OPERATOR of the facility. - 66106 <br /> IdPlt <br /> [ lete page 11, the "LTndergrotmd Tank Program Fee Worksheet". <br /> 5, Submit the appropriate fees and comp <br /> t l '6, Complete all questions on page 10,the Public Health Services-Environmental Health Division( S-gIDe <br /> "Under-ground Storage Tank Disposition Tracking Record", except triose requiring signature <br /> of tank removal. The bolder of the permit sball be responsible for ensuring that this form is completed <br /> and returned to PHS-EHD within 30 days of the tank removal. <br /> 1b' [ Submit a "Site Health & Safety Plan." as `an addendum to this application, to address all potential <br /> 7, <br /> barards for this specific job site. Refer to the Site Safety Play Guidznee Document for specifics.li � l�f ty is located ouLide of the city limits, submit a "Ball Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the i�nycpo�rporated City auilcje g}3eP L <br /> pursuant to the Uniform Building Code STD 70-11. Sf'+' P�v �C�'P C T T <br /> rC <br /> 9• Obtain a "Grading and Excavation Perm• " from the City of Tracy Building Division prior to PHS- <br /> [�� EID approval of the closure plan. <br /> The maximum review time for Closure Plans is 15 working days from receipt of the adwuately <br /> completed plan, If gross deficiencies are identified,an addendum will be required with a$78.00/hour fee <br /> and the review will begin on the date of resubmittal. <br /> 4—TaAC1 <br /> Submit verification of ire fire permit from the appropriate fire district at the removal inspection• <br /> [] 12. Advance inspection notice of at least 48 hours is reguired by PHS-EHD. <br /> Eli 23 007 (Revised 11/1/92) page 1 <br /> .A I)Msion of San Joaquin Counq Health Care Services <br />