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f - <br /> PUBLICEALTH S, ��� Sal �V tj�. 001 <br /> SAN JOAQUIN COUNTYUClssowo AwY <br /> ENVIRONMENTAL HEALTH DI} -� <br /> F; , r !• . . <br /> 13 <br /> Ernest M. Fujimoto, M. D., M.P.H., Acting I ealth 661cer <br /> c �P <br /> 304 E. Weber Ave., Third Floor • P. O. Box 388 • Mockfori;CA 95201-0388 <br /> 209/468-3420 .' <br /> APPLICATION FOR PERN11 T CLOSE _•.;; ,� <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS • . sP� <br /> [. GENERAL INSTRUCTIONS: `"`�� <br /> POAoiddd 0 <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 /> [y ?. Include a detailed site map on a separate sheet of paper, showin�QB�Ipgrl�9lf;t ,a tC�s1,n PP <br /> streets, adjacent properties(north toward the top of.the page), rWtSl�i�i� � r�� e <br /> buildings, underground public utility lines(including water, sanitary sftqq� t� l <br /> of piping from tank to dispensers. If underground utilities are not included on the site map, ust state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> 3. Complete page 3, "Application for Underground Storage Tank Closure Permit". <br /> [ J 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 /> [ J 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division(PHS-EHD) <br /> "Underground Storage Tank Disposition Tracking Record", except those requiring a signature and date <br /> of tank removal. The holder of the permit shall be responsible for ensuring that this form is completed <br /> 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 <br /> hazards for this specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> ( ] 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required <br /> by 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 City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> [ ] 10. 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 578.00/hour fee <br /> and the review will begin on the date of resubmittal. <br /> [ J 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> [ J I_'. Advance inspection notice of at least 48 hours is required by PHS-EHD. <br /> EH 23 046 (Revised 7/10/96) Page I <br /> A D:%inion rt pan Jua,jum County He.ilth lire Services <br />