SITE HISTORY - Laserfiche WebLink

Home Browse Search

A = 0 PUBLIC HEALTH SERVICES �o SAN JOAQUrN COUNTY ENVIRONMENTAL HEALTH DIVISION ` Karen Furst, M.D . , M.P.H., Health Officer 304 East Weber Avchue, Third Floor Stockton, CA 95202 209/468-3420 APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS I . GENERAL INSTRUCTIONS : y� t/ 1 . Submit all information in triplicate. Answer all questions, leaving no blanks . One copy will be returned to the applicant with comments , ✓ 2 . Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s) , piping, streets , adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water wells , buildings, underground public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank m 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 . t/ 3 . Complete page 3 , " Application for Underground Storage Tank Closure Permit" . Note: Sampling firm shall be an independent third parry from the contractor. /4. Complete page 9, "Authorization to Release" . This form must be signed and dated by the OWNER/OPERATOR of the facility. 15 . Submit the appropriate fees and complete page 11 , the "Underground Storage Tank Program Fee Worksheet " , 6 . Complete all questions an page 10, the Public Health Services-Environmental Health Division (PHS- EHD) "Underground Storage Tank Disposition Tracking Record" , except those requiring a signature and date of tank removal . The holder of the permit shall be responsible for ensuring that this form is completed and returned to PHS-EHD within 30 days of the tank removal . /7 . Submit a "Site Health & Safety Plan" 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. err �q /8 . If facility is located outside of the city limits, submit a "Backfill Excavation 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 Excavation Permit" from the City of Tracy Building Division prior to PHS- EHD approval of the closure plan. 10. ' The 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 S78 . 00/hour fee and the review will begin on the date of resubmittal . 11 . Submit verification of the fire permit from the appropriate fire district at the removal inspection. 12. Advance inspection notice of at least 48 hours is required by PHS-EHD . EH 23 046 (Revised 10/19/98) Page 1 A Division of Sa Joaquin Counn 14, im Carc Sc:vica