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PUBLIC HEALTH SERVICES <br /> . -7� } `► c <br /> SAN JOAQUIN COUNTYJ <br /> JOGI KHANNA M D.M P IF e 1 <br /> flealth O1IKCf <br /> P O Box 2009 • (1601 East 112zelton Avenue) a Stockton.Ca forni1195201 X41 d 40 r <br /> (209) 468 3400 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE 1ANKS 5 YOR1NG 11AZARDOUS MAT E <br /> GENERAL INSTRUCTIONS: <br /> i <br /> [ J 1. 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 of paper,showing the location of the tanks(s), piping, <br /> streets,adjacent properties (north toward the top of the page), nearby septic tanks,leachltelds,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 most state in writing that USA Dig will be contacted prior to excavation activities. ' <br /> t <br />[ ] 3 Complete page 3, "Application for Underground Tank Closure Permit". <br />[ , 4 Complete page 9, 'Authorization to Release Analytical Data'. This form must be signed and dated <br /> by the OWNERIOPERATOR of the facility. <br />[ ] S. Submit the appropriate fees and complete page 11,the"underground Tank Program Fee Worksheet". <br /> 1106 Complete all questions on page 10, the Public Health Services-Environmenlal Health Division ' <br /> (PHS EHD) 'Underground Storage Tank IMpositlon Tracking Record', except those requiring a <br /> signature and date of lank removal The holder of the permit shall be responsible for ensuring that <br /> this form Is completed and returned to PIIS-El ID 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 'itackllll 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. Oblain a "Grading and Excavation Permli" from the City of Tracy Building Division prior to PHS- <br /> MID approval of the closure plan. - <br /> [ 10 The maximum review time for Closure Plans is IS working days from receipt of the adequately <br /> completed plan If gross deficiencies are Identified,an addendum will be requ[Fed with a$78 001hour <br /> fee and the review will begin on the date of resubm[lial. <br /> [ 11 Submit verification of the fire permit from the approptiate lire district at the removal inspection. ] <br /> [ <br /> 12. Advance Ins cellon notice of at least 48 Fours is required by PIIS-EI ID <br /> i <br /> i <br /> 11001 (Revised 11/1192) Page i I I ?, � 0 I <br /> f <br /> A DMilon of Son Josquln County itealth Cwt serdces � tt ' <br />