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\(1�� UBLIC HEALTH SEOVIC S <br /> a SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. k <br /> a Health Officer <br /> �r�sb Box 2009 . (1601 East Hazelton Avenue) Stockton,California 95201 <br /> (209) 468-3400 <br /> LNJQ�C � APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> [1� 1. 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 location 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 /> 0/3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> 14IZ. Complete page 9, "Authorization to Release Analytical Data". <br /> . Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet". <br /> [ � Describe on pages 4&5 the decontamination techniques if applicable,material(s) utilized for rinsate, <br /> transportation and/or storage of hazardous waste generated on site, and specify the responsible <br /> party(ies) who will be disposing!of waste generated on site. <br /> J <br /> [ 7. D cribe on page 5 the method for put ing and/or inerting tank(s) and pipin . <br /> 8. Describe on age 5 in detail how soil arCd/or water samples beneath the tanks and piping will be <br /> [� Pg P ( } PP g <br /> obtained. <br /> [ f 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,f9r1n is completed and returned to HS-EHD. z � - <br /> / � �i t✓�uh� � ro n-a'4`-P.t`S 7`� �� ,l u�7S� r� <br /> [`,]tel/ 10. Submit a "Site Health & Safety Plan", 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 /> 4 <br /> 1. 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 /> [vfi' 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 $53.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> 14. Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal <br /> appointment). <br /> 15. Advance inspection notice of at least 48 hours is required by Public Health Services. <br /> Page 1 <br /> A Division of San Joaquin County Health Care Services <br />