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7p(iy � <br /> 7 UBL.�I+C HEALTH SAV <br /> ICES <br /> SAN JOAQ ;•IN COUNTY � ; tez j0(.;I KHAN,1 .NI.D.M,PH � <br /> Hesit�Ofticer <br /> P.O. Box 2009 • (1601 East Hazelton Avenur) 0 Stockton, California 95201 <br /> (209) 468-3400 <br /> APPLICATION FOR PER3IIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> ( <br /> I. Submit all information in triplicate. One copy is returned to the applicant with comments. <br /> ( ] 2. Include a detailed site map, on a separate sheet of paper, showing tank Iocation and type, piping, <br /> streets and adjacent properties (north toward the top of the page),location of the nearby septic tanks, <br /> leachfields,wells,buildings,underground public utility lines(including water,sanitary sewer and storm <br /> sewer), and distance of piping from tank to dispensers. <br /> ( 3. Complete page 3, 'Application for Underground Tank Closure Permit'. <br /> ( 4. Complete page 9, 'Authorization to Release Analytical Data'. <br /> a <br /> 5. Submit the appropriate fees and complete page 11,the'Underground Tanis Program Fee Worksheet'. <br /> ( 6. Describe on pages 4&5 the decontamination techniques if applicable,material(s) utilized for rinsate, <br /> yJA E transportation and/or storage of hazardous waste generated on s e andGgecify the respousible <br /> party(ies) who will be disposing of waste generated on site. r� .�, y✓�qy :,& <br /> �- <br /> 7. Describe on page 5 the method for purging and"/or inerting tank(s) and pipe <br /> ( 3 Descnbe on page 5 in detail how soil and/or water samples beneath the tank(s) and piping will be <br /> obtained. <br /> [� 9. Complete the pertinent section of page 10,the Public Health Services-Environmental Health Division <br /> (PHS-EHD) 'Underground Tank Disposition Tracking Record'. The holder of the permit shall be <br /> responsible for ensuring that this form is completed and returned to PHS-EHD. <br /> (�] 10. Submit a "Site Health & Safety Pian", as an addendum to this application, to address all potential <br /> hazards for this specific job site, Refer to Site Safety Plan Guidance Document for specifics. <br /> [ ] 11. Submit a 'Compaction Report' as required by the County of San Joaquin Building Department and <br /> - it's incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1. <br /> [ 12. Obtain a "Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> li <br /> �� [ ) 13. The maximum review time for Closure Plans is 15 working days from receipt of the adequately <br /> completed plan. If gross deficiencies are identified,an addendum will be required with a S53.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> i ( ] 14. Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal <br /> inspection). <br /> ( ] 15. Advance inspection notice of at least 48 hours is required by Public Health Services. <br /> Page 1 <br /> A Divuvm of Sian Jcnquin C+gunny Health Care SLYNccs <br /> .I <br />