ARCHIVED REPORTS_XR0003521 - Laserfiche WebLink

Home Browse Search

PUBLIC HEALTH SERVkES SAN JOAQUIN COUNTY Q� • ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D.,M.P.H., Health Officer 304 East Weber Avenue, Third Floor- Stockton, CA 95202 j a 209/468-3420 ' APPL C TIO OR _N F r)RIVi'T TO CLOSE UNDERGROUND STORAGE TANKS STORING HAZ,p1RD()US MATERIALS ' I. GENERAL INSTRUCTIONS I 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, t 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 to dispensers If underground utilities are not included on the site map, you moist state in wasting that USA Dig will be contacted prior to excavation activities. 3. Complete page 3, "Application for Underground Storage Tank Closure Permit" Note Sampling fiat shall be an independent third parry from the contractor. 4 Complete page 9, "Authorization to Release". This forts moist be signed and dared by the OWNERJOPERATOR of the facility. S Submit the appropriate fees and complete page 11, the "Underground Storage Tank Program Fee Worksheet" 6 Complete all questions on page 10, the Public Health Services-Envtronmental 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 [ ]N14, 8 If facility is located outside of the city limits, submit a 'Backfill Excavation Certificate" as required by ' the County of San Joaquin Budding Department and the incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-11. ' ( ]M/A,9 Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PH$- EHD approval of the closure plan 10 The maximum review time for Closure Pians is 15 working days from receipt of the adequately ' completed pian. If gross deficiencies are identified, an addendum will be required with a $18 00/hour fee and the review will begin on the date of resubmittal. ' [ ] N\/All Submit verification of the fire permit from the appropriate fire district at the removal inspection. 0 12. Advance ms=tion nonce of at least 48 hours is re urrsd by P -E D ' EH 23 046 (Revised 10/19/98) Page i ' A Division of San Joaquin Caunry Healrh Cue Services