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PUBLIC!H <br /> EALTH SERVICES Po4!N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION }r 1 n m A <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Hea1tW6ftP s,,_ , <br /> 304 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95901,03 <br /> 209/468-3420 <br /> f) <br /> fi LI , <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS,;,, , <br /> GENERAL INSTRUCTIONS: <br /> fall 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned <br /> to the applicant with comments. <br /> (� 2. Include a detailed site trap 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 wells, <br /> buildings,underground public utility lines(including water, sanitary sewer and storm sewer), and distance <br /> of piping from tank to dispensers. If underground utilities are not included on the site map, you must state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> f l ' 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 by <br /> the OWNER/OPERATOR of the facility. <br /> 5. Submit the appropriate fees and complete page 11, the "Underground Tank Program Fee Worksheet". <br /> 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division(PHS-EHD) <br /> "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date <br /> of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed <br /> 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 <br /> by 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/hour fee <br /> 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 /> [ ] 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> EH 23 007 (Revised 11/1/92) Page 1 <br /> 0 <br /> A Division of San Joaquin County Health Care Servj�s <br />