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r <br /> PUBLbe I SERWICES <br /> SAN JOAQUIN COUNTY r.) <br /> ENVIRONMENTAL 11LAU'1I DIVISION <br /> I,rnesl M. hq(intl> o, M.U., h1.1'.II., Acting Ilellitit Officer <br /> 445 N. San Joaquin Slrecl • P. O. i)ox JAI! • Slocklon, CA 95101-0388 �kikditit' <br /> 20914611-3420 <br /> Al'I'LICATION FOR I'LltN111"M CLOSE <br /> UNDERGROUND 51'0ItAGE'1'ANKS STORING 11AZARDUUS MATERIALS <br /> OENERAL iNSTRUC711ONS: <br /> ( I. Submit all Information In Iripllcale. Answer sill questions, leaving no blanks. One coley will be <br /> telutned to the applicant with comutenis. <br /> ( ( 2. include a detailed site map on a separate sheel of paper,showing the location of the tanks(s), piping, <br /> streets, arlOccnt propertles (north toward the top of the page), nearby septic tanks, leachflelds,water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br /> and distance of Piping from lank 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. <br /> ( � 3. comiilele pnge 3, "Applrcntlott for Underground 'rank Closure l'ernrll". <br /> f i 4. Complete page 9, "Aulbotknilou to Rclense Annlyticnl Min". j-his form must be signed and dated <br /> by the OWNITUVOPLRA7'Ort of the facility. <br /> 5. Submit the appropriate fees and complete page 11,the"Undergrouittl Tr ak Program Fee Worksheet". <br /> { fi- Complete all questions on page 10, (fie Public Health Services-Environmental Health Division <br /> (1 11S-F,111)) "E1++dergrn+ntd Stnrnge 'funk Msposllion 1'rneking Record", except those requiring a <br /> nature and Mate or tank removal. The holder (if the permit shall be tesponsible for ensuring that <br /> this rutin is completed and returned to I'I IS-EI-ID within 30 days of the tank removal. <br /> 7. Submit a "Sloe ilenlll+ & Surely 111mi" as all addendum to lids application, to address ail potential <br /> hazards for this specific job site. Refer to the Site Safety plan Guidance Document for specifics. <br /> ( ( 8. If f.acHiry is located oltisftle of the city 11mils, sulmilt a 'backfill Excavatlon Cerlilicnle" as required <br /> by the County of San .lonquii, t3udlding Department and the Incorporated City Building Departments, <br /> pursuant to the Uniform Building Code S'i1) 70-11. <br /> � ) 9_ Olitaln a "Grndiug and Excnvniiou Permit" frons the City of Tracy Building Division prior to PHS- <br /> El iD approval of the closure plan. <br /> ( ( <br /> 10. 'tete ntaxirntrnt review time for Closure Plans is 15 working days from receipt of the adequately <br /> completed plan. if gross dericier+cies are Identified,an addendum will be required with a $78.00/liour <br /> fee And the review will begirt on the date of resubmiltal. <br /> ( � <br /> 11. Submit vetificallun of the file permit from the appropriate fire district at the removal Inspection. <br /> ( � 12. Advance Insimcdon Itotice of at least 48 hours Is required by PIIS-EMU. <br /> 123 231x17 (Revised 1111/92) Page I <br /> A rliylAnn no Snit.tontliiln Omni) rlentok('are Servlcel <br />