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r <br /> e� <br /> PUBLIC HEALTH SERVICIS <br /> Pqulp <br /> SAN JOAQUIN COUNTY Q_'r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 4 <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 6 RAX <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> (] 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 tanks(s), piping, 1 <br /> streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water <br /> wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and <br /> distance 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 /> [] 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". of : Sampling <br /> firm shall be an independent third party from the contractor. <br /> [ ] 4. Complete page 9, "Authorization to Release". This form must be signed 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 10, 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 ensuring that this form is <br /> completed and returned to PHS-EHD 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 the Site Safety Plan Guidance Document for specifics. <br /> [ ] <br /> S. If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required by <br /> the County of San Joaquin Building Department and the incorporated City Building Departments, 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 fire district at the removal inspection. <br /> 12. Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> Submit Contingency Plan for over-excavation at time of UST removal (if planning to over-excavate). <br /> See "IH. SITE MITIGATION" on Page 2. <br /> evised 09/21/00) Page I <br /> A Division of San Joaquin County Health Care Services <br />