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7 C.- <br /> PUBLIC HEALTH SERVICES ulM�Q <br /> SAN;J0AQU1.N COUNT-1 <br /> A <br /> JOG KFANNA MD.,MT 14. <br /> 64 <br /> Heaiti�Officer <br /> P;O. Box 2009 • (1601 Fast Hazelton Avenue) •Stockton. California 95201 ��E 64 <br /> (209) 468.3#00 <br /> APPLICATION FOR PEP"MIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. One copy is returned to the applicant with comments. <br /> 2. Include a detailed site map, on a separate sheet of paper, showing tank location and type, piping, <br /> streets and adjacent properties (north toward the top of the page),location of the nearby septic tanks, <br /> le3chfie ids,wells,buildings,underground public utility lines(including water,sanitarysewer and storm <br /> sewer), and distance of piping from tank to dispensers. <br /> 3. Complete page 3, "Application for Underground Tank Closure Permit". <br /> 4. Complete page 9, "Authorization to Release Analytical Data". <br /> i. <br /> 5. Submit the appropriate fees and complete page 11,the'Under-ground Tank Program Fee Worksheetl- <br /> 6. Describe on-pages 4&5 the decontamination techniques if applicable,material(s) utilized for rinsate, <br /> transportation and/or storage of hazardous waste generated on site, and specify the responsible <br /> party(ies) who will be disposing of waste generated on site. <br /> 7. Describe on page 5 the method for purging and/or inerting tank(s) and piping. <br /> 8. Describe on page 5 in detail how soil and/or water samples beneath the tank(s) and piping will be <br /> obtained. <br /> 9- <br /> Complete the pertinent section of page 10,the Public Health Services-Environmental Health Division <br /> (PHS-EHD) 'Underground Tank Disposition Tracking Record*. The holder of the permit shall be <br /> responsible for ensuring that this form is completed and returned to PHS-EHD- <br /> L <br /> 10. Submit a "Site Health & Safety Plan', as an addendum to this application, to address all potential <br /> t hazards for this specific job site. Refer to Site Safety Plan Guidance Document for specifies. <br /> 11. Submit a "Compaction Report" as required by the County of San Joaquin Building Department and <br /> it's incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1. <br /> 12. Obtain a 'Gr-ading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> 13. The maximum review time for Closure Plans is 15 working days from receipt of the adequately <br /> completed plan. If gross deficiencies are identified, an addendum will be required with a S53.00/hour <br /> fee and the review will begin on the date of resubmittal. <br /> 14- Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal <br /> inspection). <br /> 15.' Advance insRection notice of at least 48 hours is required by'Public Health Services. <br /> Page 1 <br /> ATTACHMENT <br /> RE-EXCAVATION PLAN <br /> k D�xion of S;Ln jmquin C.iunry Mcult h Cue Scmccs <br />