COMPLIANCE INFO 1999-2003 (2) - Laserfiche WebLink

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PUBLIC HEALTH SERVICES; SAN JOAQ1JIN COUNTY ENVIRONMENTAL HEALTH DIVISION w:' Kaaren Furst, M.D.r r M.P.H, Health Officer` 304 East Weber Avenue, Third Floor • Stockton, CA 95202 209/463-3420 APPLIC,kTION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS I. GENERAL INSTRUCTIONS: Submit all information in triplicaa. Answer all questions, leaving no blanks. Gne copy will be returned to the applicant with comments. ] 2. Include a detailed site map on a : coarate sheet of paper, showing the location of the tanks(s), piping, streets, adjacent properties (north :award the top of the page), nearby septic iaiiks, leachfields, water wells, buildings, underground pub.1c. utility lines (including water, sanitary se N(r and storm sewer), and distance of piping from tank to dispensers. If underground utilities are not inc' . ded on the site map, you must state in writing that USA Dil, will be contacted prior to excavation activitia:. [ ] 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". Not : Sampling firm shall be an independent third_farty from the contractor. [ ] 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the OWNER/OPERATOR of the faci ity. [ ] 5. Submit the appropriate fees and .;omplete page 11, the "Underground Storage Tank Program Fee Worksheet". [ ] 6. Complete all questions on page 1), the Public Health Sery ices- EnvironmerreI Health Division (PHS- EHD) "Underground Storage Taitk Disposition Tracking Record", except thcse requiring a signature and date of tank removal. The hclder of the permit shall be responsible for ersuring that this form is completed and returned to PHS -EH 7 within 30 days of the tank removal. [ ] 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 t`ta Site Safety Plan Guidance Document for specifics. [ ] 8, If facility is located outside of the 4ity Iimits, submit a "Backfill Excavation Cp•rtifieate" as required by the County of San Joaquin Building Department and the incorporated City Building Departments, pursuant 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. [ ] 1.0. The maximum review time for Clos.rre Plans is 15 working days from receipt of the adequately completed A plan: If gross deficiencies aie identified, art addendurn will be required with a $87.00/hour fe aid the review will begin on the date of resubmittal. 1 [ ] 11. Submit verification of the fire permit from the appropriate fire district at the removil inspection. [ ] 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. •[ ] 13. Submit Contingency Plan for over-e,ccavation at time of UST removal (if planning, :o over -excavate). See "III, SITE MITIGATION" ort Page 2. EH 23 046 (Revised 09/21/00) Page 1 A Division -); .:an Joaquin County Health Care Services