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10/17/2000 03:00 2094683433 FIFTH FLOOR <br /> PACE 01 <br /> S <br /> PUBLIC HEALTH SERVICES <br /> • SAM MkQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Forst, MM, M.P.H., Health Officer � f <br /> 304 East Weber Avenue, Third Floor - Stockton, Chi. 95202 <br /> 209/468-3420 r X 1-1 <br /> APPLICATION FOR PEMI <br /> RT TO CLUSE <br /> Ur ERGROVIS IQRAGFE TAINKS STOl JWQ HAZARDOUS MATERIA S <br /> I GENERAL INSTRUCTioNS- <br /> 1 I Sub= all infertaation in triplicate Answer all questions. leaving no blanks One copy wW be returned <br /> to the applicant anth cotrirrtnnts <br /> [] 2 Include a detailed site map on a separate sheet of paper, showing the location of the tanlcs(s}, piping, <br /> streets, adjacent properties (norM toward the top of the page), nearby septic Unks, leschfields, vvater <br /> wt13s, buildings, undtrgrourd piblic misiry lines (imeluding water, swwary sewer and storm sewer), and <br /> dlstaace ofF}1oln8 from rank r4 dispensers. If undrsground utilities are not nicluded on the sate reap, you <br /> must state in writing that USA Dig will be conucted prior to excavation activities <br /> 11 3. Complete page 3. "Application for Undaripraiand Storage Tank Closure Permit". 'oz • Satnpling <br /> firm shall be an 44M9A=third 15&M from the contractor <br /> 11 4 Complete page 9, "Authorization to Release" This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility, <br /> 03 5. Subaut the appropriate flees and complete page 11, the "Underground Storage Tank Prograru Fee <br /> Worksheet" <br /> 11 6. Complete all questions on page 101 the Public Health Services~Fanvironmental Health Division (PHS. <br /> END) "Underground Storage Tank Disposition Tracking Record", except those requiring a signature <br /> and date of caulk removal The bolder of the pernia shall be respormble for ensuing that this toirm is <br /> completed and returned to PHS ERD, w1diln 30 days of the tank remoi a2 <br /> L 7 7. Submir a "Site Health dr Safety plan"as an addendum to this application, to address all potential hazards <br /> for this SpeCifie job site Refer Io the Site Safety Plan Guidance Oociancnt for specifics <br /> 13 S. If facility is located outside of the city limits, submit at "]Backfill Emayadon Certdticate" as required by <br /> the County of San Joaquin Bu &ng l epwmient and die incorporated City Building Departmous.pa3uam <br /> to the Ylnifvrm Building Code STD 70-11 <br /> 1] 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 /> E I 10 The maximum review tinge for Closure Plans is 15 working days from receipt of tiv adequately completed <br /> Plan if urnss de is eneles we &atuffied an aMdlerni..h,=ttii.1..1 be '",.1,wiSGd ,�,.,i'w a wv? Whour LOW-W- a d uw <br /> review wild begin on clic date of irsuhmittaI <br /> [ ] 11 Submit verification of the fire pertnit�from the appropriate fire datriet at the removal inspection <br /> I l2 Advzme inspection nottee of at)eastl48 hours is r aired by PHS-EHD <br /> C] 13 Submit Contingtacy Plan fol over-exi�avadotz u time of LST removal(if piaxm g to over-excavade) <br /> See "Iirl SITE MITIGATIQN" ars page 2 <br /> 4111 23 046 (Revised 09121/()0) 1 Page 1 Post-its Fpr Note <br /> �¢ � L 767471 <br /> ► <br /> Coll Di%iaion of 5.1rt Jvaqun <br /> c4Mept <br /> Fax A <br /> Fx1z iF y_pltW5Y�1 �AI <br />