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} } y SER Y ICESPUBLIC HEALTH SAN JOAQUIN COUNTY " ENVIRONMENTAL HEALTH DIVISION ' Karen Furst, M.D.,'M.P.H., Health Officer iP aciFp'aia 304 East Weber Avenue, Third Floor • Stockton, CA 95202 E 2091468-3420 i APPLICATION FOR PERMIT TO CLOSE UNDERGROUND STbRAGE TANKS STORING HAZARDOUS MATERIALS 1. GENERAL INSTRUCTIONS: [ ] 1. f Submit all information in tripikatel Answ r all questions, leaving no blanks. On copy will be returned I o the applicant with commer ts. 712 Ctt �' C'N�C�'1 , [y]� 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, leachfieids,water wells, buildings, underground public utility lines(including water, sartitary 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 wilbbe contacted prior to excavation activities. Complete page 3 "A licadon for Underground Storage Tank Closure Permit". 3. Comp p g PI? [ — i [ 4. Complete page 9, A uthorization to Release". This form must be signed and dated by the OWNERIOPIIRATOR of the facility. ( 5. Submit the appropriate fees�afid complete page 11, the "Underground Storage Tank Program Fee Worksheet". 6. Complete all questions on 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. 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. 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 [ j completed plan. If gross deficiencies are identified,an addendum will be required with a S78.G01hour fee , and the review will begin on the date of resubmittal. I ( ] I 1 Submit verification of the fire permit from the appropriate fire district at the removal inspection. j ] 12. Advance inspection notice of at least 48 hours is required by PHS-EHD_ EH 23 046 (Revised 9/11/96) Page l A'Division of San Joaquin County Health Care Services j