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w5 -ki+c) <br /> � - - UBL HEALTH SEI \/ICES , P �a <br /> SAN iOAQUIN COUNTY <br /> YX .10GI KHANNA NI.D.,,NiT H <br /> Health Officer <br /> 1992 P.O. Box 2009 0 (1601 East Hazelton Avenue) 0 Stockton, California 95201 4.6B 6 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH APPLICATION FOR PERMIT TO CLOSE <br /> PERMIT/SERVICUNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> 1- Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(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 tank to dispensers. If underground utilities are not included on the site <br /> map,you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> 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 /> S. Submit the appropriate fees and complete page 11,the'Underground Tank Program Fee Worksheet'. <br /> 11.] Complete all questions on page 10, the Public Health Services-Environmental Health Division <br /> PHS-EHD nderground Storage Tank Disposition Tracking Record", except those requiring a <br /> signature and d to of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this forth 4r, m <br /> ! ., mpleted and returned to PHS-EHD within 30 days of the tank removal. <br /> ILT/ Subm a *Site It & Safety Plan* as an addendum to this application, to address all potential <br /> hazar hs specific J site. Re <br /> fer,w the Site Safety Plan Guidance Document for specifics. <br /> S. If facility is located- of th wits, submi "Backfill Excavation Certificate" as required <br /> by the County of San Joaquin Bu' Departme and the incorporated City Building Departments, <br /> 2 ty)]� <br /> "Site <br /> specific <br /> ubm' <br /> Ile and <br /> pursuant to the Uniform Building Code STD 7?11. <br /> 9- Obtain a "Grading and Excavation Permit" from the City of jT (cy7Building Division to PHS- <br /> EHD approval of the closure plan. 1, <br /> 10. The maximum review time for Closure Plans is 15 working days from receipt of t e adequa <br /> completed plan. If gross deficiencies are identified,an addendum will be required with a$5"!7 <br /> fee and the review will begin on the date of resubmittal. <br /> 11. Submit verification of the fire permit from the appropriate fire district at the removal ' pection. <br /> 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> EH 23 007 (Revised 7/10/92) Page 1 <br /> A Division of San Joaquin County Health Circ Services <br />