Laserfiche WebLink
10/17/2000. 09: 00 20946834'13 FIFTH FLOOR PAGE 01 <br /> PUBLIC HEALTH SERVICES <br /> SAN, OA LJ N COUNTY e c c <br /> 1 Q x <br /> ENVIRONMENTAL HEALTH DIVISION n� <br /> Karen Furst, M.D., M.P.H., Health Officer (W ECL I <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 OCT 2 3 2000 <br /> APPLICATION FOR PERMIT TO CLOSE ENVIRONMENT HEALTH <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS�,U( /4WVICES <br /> I. GENERAL INSTRUCTIONS: <br /> 11 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 map on a separate sheet of paper, showing the location of the tatilcs(s), piping, <br /> streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water <br /> wens, buildings, underground public utility Imes (including water, sanitary sewer and storm sewer), and <br /> di5iance of piping from tank to dispensers. If underground utilities are not included on the site map, you <br /> must state in writing that USA Dig will be contacted prior to excavation activities. <br /> 13 3. Complete page 3, "Application for Underground Storage Tank Closure Permit Not : Samplin¢ <br /> firm shalt be an independent third nam from the contractor. <br /> [] 4. Complete page 9, "Authorization to Release". This form must be sighed 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 questions on page 101 the Public Health Services-Environmental Health Division (PHS- <br /> EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br /> and date of tank removal. The holder of the permit shall be responsible for emrttlg that this Torn is <br /> completed and returned to PHS-END 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 hazards <br /> for this specific job site_ Refer to thJie Site Safety Plan Guidance Document for specifics. <br /> If facility is located outside of the city limits, submit it "IlackPrll Excavation Certlficate" as required by <br /> the County of San Joaquin Building li epartcaem and the incorporated City Building Depanments,pursuant <br /> 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-EHD <br /> approval of the closure plan. <br /> [) 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed <br /> plan. if gross deficiencies are identified, an addendum will be required with a$87-00 hour fee and the <br /> review will begin on the date of resubmittal. <br /> [ ] 11. Submit verification of the fire permit from the appropriate fore district at the removal inspection. <br /> [ ] 12. Advance inspection notice of at]east 48 hours is required by PHS-EHD. <br /> (] 13. Submit Contingency Plan for over-e vation at time of UST removal(if planting to over-excavate). <br /> See "III. SITE,MITIGATION" on age 2. _ <br /> EH 23 046 (Revised 09/21/00) Page 1 Post-it"Fax Note - 7671 oatr� a°�► <br /> I <br /> A Division of San Joaquin Col , �e-vi From <br /> Ca.Depi. cp. PHS D <br /> ' PFl°ne tl Ph°nC 11 <br /> ParR.,�y__ 5�-292Z Fa>,x <br />