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PUBLIC H?ALTH SERVI(! S SAN JOAQUIN COUNTY UX ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer CgLf FbRa` 304 East Weber Avenue, Third Floor • Stockton, CA 95202 2091468-3420 APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS I, GENERAL INSTRUCTIONS: 1, Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the applicant with comments. Include a detailed site map on a separate of paper, the page)nearbylseptic tanks, lea caon of the hfie ds,water streets, adjacent properties (north toward the top of wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not included on the site map, you ` must state in writing that LISA Dig will be contacted Briar to excavation activities. / G C,4 ir Complete page 3, "Application for Underground Storage Tank Closure Permit"• of SamPlin firm shall be an rode endent thirdrty from the contractor. � 4, A Complete page 9, "Authorization to Release". This form must be signed and dated by the,�cz+r,ak OWNER/OPERATOR of the facility. tf*�' P page g Storage am Fee ni Submit the appropriate fees and complete a e 11, the "Underground a Tank Program arc(, ti15 Wo ksheet". Il 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division (PHS- 6w EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD within 30 days of the tank removal. ctit` 7. Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential hazards for this specific job site. Refer to the Site Safety Pian Guidance Document for specifics. 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate as requi pursuant by the County of San Joaquin Building Department and the incorporated Ci BuildingDepartments, to the Uniform Building Code STD 70-11. 9. Obtain a"Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS-EHD approval of the closure plan. 10. The maximum review time for Closure Plans is working days from receipt of the adequately completed pian. If gross deficiencies are identified, added will be required with a $87.00/hour fee and the review will begin on the date of resubmittal. 1 `? Submit verification of the fire permit from the appropriate fire district at the removal inspection. 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. Submit Contingency Plan for over-excavation at time of UST removal (if planning to over-excavate). See "III. SITE MITIGATION" on Page 2. 'Revised 09121100) Page 1 A Division of San Joaquin County Health Care Services