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PUBLIC H; ALTH SERVI(-..ES <br /> - cuiN <br /> SANN JOAQL-LNT COL:V'Ty <br /> EN <br /> NVIROMENTAL HEALTH DIVISION r S. <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 30= East N--eber Avenue, Third Floor • Stockton, CA 95202 Ra� <br /> 209/=68-341-20 'br <br /> J0r,9,1 <br /> c <br /> Nt <br /> APPLICATIOn FOR PERM1— <br /> VIP E <br /> IT TO CLOSE p' rAL HEAD � <br /> UNDERGROLI'D STORAGE TA:tiTv STORD4G HAZARDOLS �t.�TERi�L�/17/SVl'C`S . H <br /> I. Gc. --AL LNSTRtiCT?O!vS: <br /> ( ] - Submit ail in:or=arion 'in u piicare. Aasw-e,. ail euestiors, leaving no bian;s. One copy will be saamed <br /> to me anuiicant wit¢cammens_ <br /> ( ] 2. include a de:aRed Site t^_aD on a Sc-Da-are Site; of Dave:. SCOwj�iz ch lOcadCn Oi ch canks(S). o r)sat <br /> S"ups, adiaCeIIi OrOOe.'tleS(IIOLSh Coward''-Re :OD Ofzi,.e nagej, nearby S^dc•._*.SS. lead efts. ware:we;;S. <br /> bulldmgS, !lade:?*'OIIId pL'bIIC:SCI11L`r tines i'�:iudmg W;Ce Sanli=1 Sew-:and a.0—aa iC::e:), and iatS-�ce <br /> Of plum-2 0ni'=k io dispensers. L=underpound udHaes acct act mc"'c" On me S:Ce T."n, v musz State <br /> u wridne tac USA Dig will be :OnuaC:Ci nr:Or t0 t zavation ac^.vldes. <br /> [ j _. Compiem nage :, -Anoiication for Underground Storage Tan's Closure Pt-^mit'. <br /> Complexe page 9. 'Authorization to Release', iais for mus be ; wee a=d aced by ae <br /> OWtiER/OPI R-s.TOR of cne facility. <br /> [ ] _. Submit _e anorcoratt sees -,d c,.npiete page c_, me "L'nde ground SCoraae Tania Program Fee <br /> Worlsheet". <br /> [ ] 6. COIIIDIere til nlleSdOnS On xge l0, ti7e Public _ealm�t-llCeS-_"`r*OnS.eAiai-��L D*:vlSiOn 4PL S__:J� <br /> "Underground Storage Tank Disnositiou Tracking Record". _.coot .-eCL't71I^g a SiZmlre and dare <br /> O: C= :T=V;l. 72t "'-Older Of Se Shall be MS-0012S•aOle '.Or r.S.`_-=2 "_at M3 _o—= S :ounieted <br /> and m aed :o ?1?S-= D wlrhin Sv days of —e m=cvaii- <br /> 7. Submit a "Site Heaith & Safery Pian" as an addend= Lo ibis non ick en. co address ail notendai <br /> ra arils for : sa i is ob site. Rete: ac e Stu Sa er1 ?' Guidance Doerr ,.e=r or sae^-_ncs. <br /> 3. * :acriicv is located outside of ane r+ d=as, sub mir a 'BacW111 Exsvation Certificate" as recuired <br /> by the Countv of San Ioaeuin Building Denanment and me mcomorate^- C1ty Building Dep;:--e=s. <br /> 011175uanr :o the uniform Building Code STD 70-11. <br /> G Oct, <br /> [ 1 9. Obtain a "Grading and Excavation Permit" tom rhe C1ry of iF- .3uiidi=g Division ' <br /> prior to ?HS- <br /> E=M aoorovai of he closure oian. <br /> ( ] I0. The maximum review Lime for Closure ?tans s 15 wor:cnz days -."mm e--int of the adequareiv <br /> comniemd pian If gross derimences are identified. an addendum will be =uired wim a 573.00ihour fee <br /> and rhe review will begin on the date of:esubmiitai_ <br /> ( 1 l 1. Submit verincadon of the fire pe mit zom he maroprace :ire diszncr at me --=oval iaspecdon. <br /> ( ] 12. Advanr- msnecnon nods_of at least uS hours is renuired bV ?HS 'P_ID <br /> EH 23 0045 (Revised 9/11196) page I <br /> Dhision of San Joaquin Couna` Health Care Seniq <br />