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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Unit Program Coordinators <br /> .z Donna K. Heran,R.E.H.S. <br /> 600 East Main Street Carl Borgman, R.E.H.S. <br /> Director <br /> Stockton, California 95202 Mike Huggins, R.D.I. <br /> - Margaret Lagoriorio, R.E.H.S. <br /> • •. �P Laurie A.Cotulla, R.E.H.S. <br /> Telephone: ( <br /> p ) <br /> h (209 468-3420 Robert McClellon,R.E.H.S. <br /> q�fF��N <br /> Assistant Director Fax: (209)468-3433 Jeff Carruesco, R.E.H.S. <br /> Kasey Foley, R.E.H.S. <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> _ {—d 1. Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the <br /> applicant with comments. <br /> 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, streets, <br /> d$ adjacent properties(north toward the top of the page),nearby septic tanks, leachfields, water wells, buildings,underground <br /> public utility lines (including water, sanitary sewer and storm sewer), and distance of piping from tank to dispensers. If <br /> underground utilities are not included on the site map, you must state in writing that USA Dig will be contacted prior to <br /> excavation activities. <br /> 03A <br /> 3. Complete pages 3-6, "Application for Underground Storage Tank Closure Permit". of :Samplingfirm shall <br /> be an independent third party from the contractor. <br /> ^4_o$ ( 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> �]1� 5. Submit a"Service Request" form with the appropriate fees, submit completed UPC forms for Facility and Tanks <br /> (formerly State A&B forms)and complete the"Underground Storage Tank Program Fee Worksheet". <br /> 1✓1 6. Complete all questions on page 10, the Environmental Health Department(EHD) "Underground Storage Tank <br /> Disposition Tracking Record",except those requiring a sip-nature and date of tank removal. The holder of the permit shall <br /> be responsible for ensuring that this form is completed and returned to EHD within 30 days of the tank removal. <br /> Sib tv':%_W 0 7. Submit a"Site Health&Safety Plan"as an addendum to this application,to address all potential hazards for this <br /> (0-4— °$ specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br /> [� 8. If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required by the ik County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform <br /> Building Code STD 70-11. E.9;s'H n c P e_o.— 9 r a-,Je A re — s d. <br /> 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of <br /> the closure plan. <br /> (t� 10. The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan. If <br /> gross deficiencies are identified,an addendum will be required with a$98.00/hour fee and the review will begin on the date <br /> of resubmittal. <br /> 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> Pet C-k*, <br /> 12. Advance inspection notice of at least 48 hours is required by EHD. <br /> 13. Submit Contingency Plan for over-excavation at time of UST removal(if planning to over-excavate). <br /> See"III. SITE MITIGATION"on Page 2. <br /> EH 23 046 (Revised 12/31/07) 1 <br />