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PUBLI1 HEALTH SEI&ICES ePo�1N, <br /> SAN JOAQUIN COUNTY 2' n y <br /> ENVIRONMENTAL HEALTH DIVISION Q. <br /> N: a <br /> Ernest M. Fujitnoto, M.D., M.P.H., Acting Health Officer <br /> 445 N. San Joaquin Street • P. O. Box 388 • Stockton, CA 95201-0388 <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> [v] 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be <br /> returned to the applicant with comments. <br /> [ ] 2. Include a detailed site map on a separate sheet of paper,showing the location of the tanks(s), piping, <br /> streets,adjacent properties (north toward the top of the page),nearby septic tanks,leachfields,water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br /> and distance of piping from tank to dispensers. If underground utilities are not included on the site <br /> map, you must state in writing that USA Dig will be contacted prior to excavation activities. G <br /> [�J 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> [/J 4. Complete page 9, "Authorization to Release Analytical Data". This form must be signed and dated <br /> by the OWNER/OPERATOR of the facility. <br /> [/] 5. Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet". <br /> [v] 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division <br /> (PHS-EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a <br /> signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PHS-EHD within 30 days of the tank removal. <br /> [v] 7. Submit a "Site Health & Safety Plan" as an addendum to this auolimtion, to address all potential <br /> hazards for this specific ioh cir, o <- -e Document for specifics. <br /> [ ] <br /> S. If facility is located ou Ion Certificate" as required <br /> 1J� by the County of San Jc City Building Departments, <br /> pursuant to the Unifor (� <br /> [a 9. Obtain a "Grading and �z- .s ' ng Division prior to PHS- <br /> [v] 10. The maximum review ti: +ipt of the adequately <br /> completed plan. If gross quired with a S78.00/hour <br /> fee and the review will t <br /> [y] 11. Submit verification of th :he removal inspection. <br /> [v) 12. Advance inspection notic <br /> EH 23 007 (Revised 11/1/92) <br /> A Division of San Joaquin County Health Care Services <br />