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1JALTH SERVICES z4/►a�.FoG <br /> PUBLIC , <br /> SAN JOAQUIN COUNTY <br /> �►: 1 <br /> JOGI MANNA M.D.,M.P.I1. '• i <br /> lialthOfEiccr c+ •* <br /> P.O. Box 2009 • <br /> 1601 East I lazelton Avcnuc) • Stockton, Cilifornla 95201 <br /> (209) 468.3400 <br /> !'PLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATER MA ; <br /> GENERAL INSTRUCTIONS: <br /> ; <br /> t, Submit all Information In triplicate. Answer all questions, leaving no blanks. one copy will be <br /> returned to the applicant with comments. <br /> 2. Include a detailed site map on a separate sheet e`paper,showing the location of the tanks(s), piping, <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), <br /> and distance of piping from tank to dispensers. If underground utilities are not Included on the site <br /> map, you must state in writing that USA Dig will be contacted prior to excavation activities. <br /> 3. Complete page 3, 'Application for Underground Tank Closure Permit". <br /> 4. Complete page 9, "Authoriznllon to Relense Asinlyticnl Data". This form must be signed and dated <br /> by the OWNER/OPERATOR of the facility. <br /> 5. Submit the appropriate fees and complete page 11,the"underground Tank Program Fee Worksheet". <br /> Complete all questions on page 10, the Public Health Services-Environmental Health Division <br /> �+ (PIIS-EIID) "Underground Storage Tank 1)Isposillon Trocking Record', except those requiring a j + <br /> signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PIIS-EI-lD within 30 days of the tank removal. ' <br /> 7. Submit a "Site licallh & Safety Plnn" 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 specifies. <br /> 8. if facility Is located outside of the city limits, subrtnil 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 7U-11. <br /> 9. Obtain a "Grading artd Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EIID approval of the closure plan. <br /> 10. 1-he maximum review time for Closure Plans Is 15 working days from receipt of the adequately <br /> completed plan. If gtoss deficiencies are Identified,an addendum will be required with a $78.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> 11. Submit verification of (lie fire permit from the appropriate fire district at the removal Inspection. I� <br /> I <br /> + <br /> 12. Advance Inspection notice of at least 48 hours Is required by PI IS-El ID. <br /> + <br /> f <br /> i <br /> 123 007 (Revised 11/1192) Page I , r <br /> � � f <br /> A D tvt,lon or Sm Imquln county 11c2M[ane ScrAces �► ;' <br />