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PUBLIC AFALTH SERVICES SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.RH., F.cvJth Officer 304 Fast Weber Avenue,Third Floor • Stockton, CA 9520 209/468-3420 PLICATION FOR PEP f TO CLOsE UNDERGROUND 5TORAGE T.ANKSTORING 14-AZA (:S MATERIALS 1. GENERAL INSTRUCTIONS: J 1 Submit ail information in triplicate. Answer ail questions, leaving no blanks- One copy will be rerumcd to rhe applicant with comments. i 2- Include a detailed site map on a separate sheet of paper, spewing the location of he raJu S>, piping, sweets, adjacent properties (north toward the top of the page), nearby septic ranks, ;eachtields, water wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and di—stance of piping from tank to dispensers. If underground utilities are not included on the site map, you must state in writing thZE USA Dig will be contacted prior to excavation activities. t J 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". Mote- Sampling firm shall be an independent third party from the contractor_ [ 1 4. Complete page 9, "Authorization to Release-. This form must be signed and dated by the OVV'1I'ERtOPERATOR of the facility. Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee Worksheet". ( ) 6. Complete all questions on page 10, the Public Health Services-Environmentai Health Division (PHS- EHD) "Underground Storage Tank Disposition Tracking Record". except those requiring a signature and date of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD within 30 days of ube tank removal. [ ) 7. Submit a "Site Health & Safety Pian" as an addendum to this application, to address ail potential hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. ( ? K. If facility is located outside of the city limits.. submit a "Backfill -Excavation Certificate" 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, J 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- EHD approval of the closure plan_ l ] 10. Tie maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If gross deficiencies are identified, an addendum will be required with a $78.00/hour fee and the review will begin:on the date of resubmittal. ( J 1;. Submit verification of the fire permit from the appropriate fire disincr at the removal inspection. (} 12. Advznce inaction notice of at least 48 hours is reaum!d by PHS-EHD. EH 23 046 (Revised 10/19/98) Pacc 1 A Division of San Joaquin Counry i-icnlch Care Sen TCC3 61d9t'=1' F F, l—Pt]