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10/17/2000 09;00 2094683433 FIFTH FLOOR ppGE 01 <br /> PUBLIC HEALTH SERVICES <br /> . <br /> a . <br /> SAN JOAQLII,�I COUNTY 5. c <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Frust, M.D.,M"P"H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 p..' <br /> 209/468-3420 r—AX 4 68 - 3 g 3 3 <br /> APf'j,ICATION FOR PER1tIT TO CLOSE <br /> 1JNDERGRtT1[Nn STORAGE TANKS STORING HATARDCn1T>tiR1AIS <br /> 1. GENERAL MMUCTIONS: <br /> l l L Submit all in3armadon to nipucato. Answer all questions, leaving no blanks. One Copy will be returned <br /> to the applicant with comments. <br /> C 7 2. Include a detalled site map on a separate sheet of Paper, slwwing the location of the twlcs(s), piping, <br /> sneers, a(lacetu properties (tuttth mward 1Le top of the page), nesrby septic tanb, leachfields, water <br /> we9s, buildings, uadcground pibliC utility lines (loCluding water, sanitary sewer and storm sewer), and <br /> distance of piping from tank to dispensers, If underground utilities are not mcluded on the site map, you <br /> must scam in writing that USA Pia will be cantaeted prior to excavation activities. <br /> (] 3. Complete page 3. "Application for Underground $forage Tank Closure Parma". j: Samplit <br /> firm shall be an ittdetxndeat third nam from the contractor. <br /> 13 4, Complete page 9. 'Authorization to Release"- This form must be s3gtted and dated by the <br /> OWNER/OPERATOR of the facility. <br /> [] 5. Submit the appropriate fees and complete page 11, the 'Underground Storage Tank Program Fee <br /> Worksheet". <br /> (] 6, Complete all gwstions on page 101 fixe Public Health Servlcea-FavirodaimW Health Division (PHS <br /> EBD) "Underground Storage Tank Disposition Trael;ang Accord", except those requIring a aigtanim <br /> and date of tank removal. The holder of the permit shall be responsible for ensuring that this lam is <br /> completed and renumcd to PHS-Ewithin 30 days of the motif removal. <br /> (] 7. Submit a "Site Healtb &Safety Plan" as an addendum to this application, to addrets all potemial hazards <br /> for This specifiic job ate. Refer to dile Sim Safety Plan Guidance Document for specifics. <br /> (] B. it facility is located oueside of the ci[y limits, submit a "Backfill Ynavation CerUncate" as required by <br /> the Counry of San Joaquin Building r�epartmmt and the incorporated City Building Depaz,mme"perminit <br /> to Ofe Undbrm Buildlag Cal STD 70-11. <br /> [] 9. Obtain a "Grading and Fararation Permit" from the City of Tracy Building Divdioe prior to PHSEHD <br /> approval of the closure plan. <br /> [] 10. The maximum review time for Clutge Plans is 13 working days from receipt of the adequetedy completed <br /> plan. If gross deficiencies are ideadr)ed, an addendum will be required with a$87.001hcntt fee and the <br /> review will begin on the date of tWubtittal. <br /> [ ] I1. Submit verification of the fire pertmofrom me appropriate fire district at the removal Inspection. <br /> [ ] 12. Advance insoectiom notice of of)e 48 hours is required byr PHS-MD. <br /> [] U. Submit Coatingency Plan for over+.1{Cavauon at time or UST removal(if piarremg to over-ezcavau:). <br /> See "111. SITE MITIGATION'on Flagg 2. <br /> EH 23 046 (Revised 09/21/00) Page I post r?ax Note 76�T ons _ ► <br /> A UiAsion of S,.n Juonvin Col 1'n -!,tcv <br /> Co"Dapt C. <br /> PhOV4 Y Pllons a <br /> FKf - -4-2 Z r <br /> Z0 in DNI DI ND V ,ti ZZ69 C69 L01 %V3 92:9T 00/CZ/0T <br />