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PUBLIC'OHEALTH SERVICES 1QT4u!N_ �a� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION "`� a ►`� <br /> Karen Fursr, M.D., M.P.H., Health Officer � r <br /> 304 East Weber Avenue, Third Floor• Stockton, CA 9 202 <br /> 249/468-34201: <br /> APPLICATION FOR PERNUT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> 1. 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 tanksis), piping. <br /> streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfieids, 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 snap, you <br /> must state in writing chat USA Dig will be contacted prior to excavation activities. <br /> [� 3. Complete page 3, "Application for Underground Storage Tank CIosure Permit"_ Note: Sampling <br /> firm shall be an independent third parry from the contractor. k;.II12G�5 e pf4 7tzl- <br /> [ 4. Complete page 9, "Authorization to Release". This forth must be signed and dated by the <br /> OWNERIOPERATOR of the facility. <br /> ] S. Submit the appropriate fess and complete Rage 11, the 'Underground Itorage TankJ�anz FPe <br /> Worksheet". c.4t�- [9,1,61 ..2-� <br /> :L,�. <br /> [ ] 6.) C plete all questions on page 10, the Pubiic He Strvic Environmental Health Division (PHS- <br /> `-- EHD) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br /> and date of rank removal_ The holder of the permit shall be respoasfole for ensuring that this form is <br /> �ampiezed and retuned to PHS-HHD w' 30 days of the tank removal. t"i fl't.L 1• . /g5 Te c7 c <br /> �J�rig fi aA-1 Il , <br /> [t]� 7. Submit a "Site Health & Safety Plan" as an addendum to this application, co address all potential <br /> hazards for dais specific join site. Refer to the Site Safety Plan Guidance Documeatt for specifics. <br /> ul If facility is located outside of the city limits, submit a "BackfM Excavation Certificate" as required by <br /> the County of San Joaquin Building Department and the incorporated City Building Departments. <br /> pursuant to the Uniform Building Code STD 70-11. <br /> 9. Obtain a "Grading and Excavation Permit" from the Ciro of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> The maximum review time for Closure Plans is 15 working days from receipt of the adequately <br /> completed plan. If Gross deficiencies are identified, an addendum will be required with a S78.00/hour <br /> tee and the 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 reouired by PHS-EHD_ <br /> EH 23 046 (Revised 7111198) Page 1 <br /> a Division of San JoaoUin County F=1rh Care Sc.-vie= <br />