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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY t <br /> N: <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health OfficerP" <br /> .cgcfFOQ�` <br /> P.O, Box 2009 • (1601 East Hazelton Avenue) •Stockton, California 95201 <br /> (209)46&3400 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> (� 1. Submit all information in triplicate. One copy is returned to the applicant with comments. <br /> TArC [1?-- 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,sanitarysewer and storm <br /> sewer), and distance of piping from tank to dispensers. <br /> (;.J/ 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> rAIT 4. Complete page 9, "Authorization to Release Analytical Data". <br /> TaT �Ii 4( 5. Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet". <br /> 6. 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 specifyrr��responsible <br /> party(ies) who will be disposing of wasteggenerated o We. ;� p1.1&0 -OS <br /> �6e��uA`t ate,e� .0/0 ,p -�, 9 l lo• O tl°�/S <br /> (►]� 7. Describe on page 5 the method for purging and/o lnerting to ) and piping. <br /> S. Describe 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 1"0,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 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 /> [ ] 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 /> btain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> [ ] 13. The maximum review time for Closure Plans is 15 working days from receipt of the adequately <br /> completed pian. If gross deficiencies are identified, an addendum will be required with a S53 0 <br /> fee and the review will begin on the date of resubmittal. fir,�r� 1ZQt7 <br /> - FIRE <br /> TO tl P Tac <br /> 14Submit verification oTArt1tS. <br /> TAT . itif the fire permit from the appropriate fire district. <br /> [ ] IF `IOU Alae. Join'l To <br /> [j 15. Advance ins ection notice of at least 48 hours is re uired by ublic Health Service DO THATt `to'j <br /> MOST <br /> 1 p,,it TwoT <br /> Page 1 (/ii G°'YlGt WCuE 1igE af�rods[ rey <br /> t''1`` tNszctl # Re <br /> A Division of San Joaquin County Ht9th Cate Saccs vivhOJ e <br />