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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY °RRutTM' <br /> ENVIRONMENTAL HEALTH DIVISION . <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 • ��' ~ <br /> �r•ea�: <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. we all uestions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. I' A � Cop t E-S <br /> [ 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br /> I� streets, adjacent properties (north toward the top of the page), nearby septic tanks le <br /> wells, buildings, underground public utility lines (includingwater, sant P achfie weds, water <br /> tart' sewer and storm sewer), and <br /> distance of piping from tank to dispensers. If underground utilities are not included on the site map, you <br /> must state in writing that USA Dig will be contacted prior to excavation activities. <br /> 3. * Complete page 3, "Application for Underground Storage Tank Closure Permit". Note: Sampling <br /> firm shall be an independent third parry from the contractor. tab— yldyyt e, -4 S4. � <br /> Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> lt' <br /> (q 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee <br /> / Worksheet". <br /> [y 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS- <br /> EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br /> and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is <br /> completed and returned to PHS-EHD 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 <br /> / hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> 8. If facility is located 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, <br /> pursuant to the Uniform Building Code STD 70-11. <br /> 9. Obtain a "Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> (] 10. 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 $78.00/hout <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 inspection. <br /> [1 12. Advance inspection notice of at least 48 hours is required by PHS EHD <br /> EH 23 046 (Revised 7/11/98) Page I <br /> A Division of San Joaquin County Healrh Care Services <br />