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PUBLIC HEALTH SERVICES SAID)OAQUIN COUNTY JOGI MANNA M D.M P If ite�lth Offal � ' P O Box 2009 0 (1601 Past 112:clton Avenue) 0 Stockton, Wlfornla 95201 �� (209) 468 3400 APPLICAI ION FOR PERMIT 10 CLOSE ' UNDERGROUND SIORAGE 1ANKS SIOIUNG HAZARDOUS MAIEIUAI.S GENERAL iNSTRUC nONS ! 11 � 1 Submit all information in triplicate Answer all questions, leaving no blanks One copy will be l returned to the applicant with comments i' 2 Include a detailed site map on a separate sheet el-aper,showing the location of(lie lanks(s), piping, streets,adjacent properties (north toward the top of the page), nearby septic tanks, leachfleids,water wells, buildings, underground public utility Imes (including water, sanitary sewer and storm sewer), ' and distance of piping from tank to dispensers If underground utilities are not Included on the site map, you must state in writing that USA Dig will be contacted prior to excavation activities ; i' 3 Complete page 3, "Application for Underground Innk Closure Permit" J 4 Complete page 9, 'Authorl:ation to Release Annlytical Dnta' 17ris form must be signed and dated ' by the OWNER/OPERATOR of the facility 5 Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet", 106 Complete all questions on page 10, the Public flealth Services-Environmental Health Division (f f IS-EIID) 'Underground Storage Tank Disposillon Tracking Record', except chose requiring a signature and date of tank removal "e holder of the permit shall be responsible for ensuring that I ' this form is completed and returned to PIIS-EIID within 30 days of the lank removal I J 7 Submit a "Site Ilealth & Snfety Ilan' as an addendum to this application, to address all potential hazards for this specific job site Refer to the Site Safety Plan Guidance Document for specifics i' 8 if facility is located outside of the city limits, submit a 'nnekrill FAcavallorr Certificate' as required by the County of San Joaquin Building Department and the Incorporated City Building Departments, ' pursuant to the Uniform Building Code STD 70-11 9. Obtain a "Grading and Exenvallon Permit* froin the City of Iracy Building Division prior to PHS- El ID approval of the closure plan i 10 111e maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan If gross deficiencies are Identified,an addendum will be required with a$78 00/hour ' fee and the review will begin on the date of resubmittal f 11 Submit verification of the rite permit from the appropriate fire district at the removal inspection j 12 Advance Inspection notice of at least 48 hours is required by PIIS-EIID i i 3007 (Revised 1111192) Page 1 iI tot. ; A U"lon of Son Josquln county Iltallh r-sre Serrlcef ,