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ENVIRONMENTAL IftEALT"EPARTMENT <br /> P....pu SAN JOAQUIN COUNTY Unit¢upervisors <br /> a... <br /> Carl Borgman,RE.H.S. <br /> ri,;" +'r'•r?� Donaa I{_xeran,RE•H•S• 304 East Weber Avenue,T�llyd moor Mike Huggins,R.E.H.S.,R.D.I. <br /> Director <br /> Douglas W.Wilson,RE.H.S. <br /> A]Olsen,RE.H.S. Stockton, California 95202-2708 <br /> Telephone: (209) 46La <br /> 8-3420 Margaret orio,RE.H.S. <br /> Program Manager gazet g <br /> c4 i:i!F...6- Laurie A.Cotulla,R.E.H.s. Fax: (209) 464-0138 MarkRobert McClelos,R. .H.S. <br /> Program Manager <br /> Mark Bazcellos,RE.H.S. <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> 1. GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to <br /> the applicant with comments. <br /> i <br /> Ltl� 2, Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s),piping,streets, <br /> adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water wells, <br /> buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance <br /> of piping from tank to dispensers. If undervrnr't; .� --— included on the site trap, you must state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". Fof : Sampling fum <br /> shall be an independent third party from the contractor. <br /> _ 4• Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> C f 5. Submit a "Service Request" form with the appropriate fees, submit completed UPC forms for Facility and <br /> Tanks (formerly State A & B forms) and complete page 11, the "Underground Storage Tank Program <br /> Fee Worksheet". <br /> [) 6. Complete all questions on page 10, the Environmental Health Department (EHD) "Underground Storage <br /> Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The <br /> holder of the permit shall be responsible for ensuring that this form is completed and returned to EHD <br /> within 30 days of the tank removal. <br /> �.� 7. Submit a "Site Health &Safety Plan" as an addendum to this application,to address all potential hazards <br /> for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> (� 8. If facility islocated outside of the city limits, submit a "Backfill Excavation Certificate" as required by <br /> the County of San Joaquin Building Department and the incorporated City Building Departments,pursuant <br /> to the Uniform Building Code STD 70-11. <br /> {a Obtain a "Grading and Excavation Permit" from the Citof Tzacy Building Division prior to EHD <br /> approval of the closure plan. - <br /> The maximum review time for Closure Plans is:15 working days from receipt of the adequately completed <br /> plan. If gross deficiencies are identified, an addendum will be required with a $89.00/hour fee and the <br /> review will begin on the date of resubmittal <br /> Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> Advance inspection notice of at least 48 hours is required by EHD. <br /> .14-- Submit Cgntingency Plan for over-excavation at time of UST removal(if planning to over-excavate). <br /> See"III. SITE MITIGATION'on Page 2. <br /> EH 23 046 (Revised 3/15/02) Page I <br />