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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNT <br /> so. ;.co Unit Program Coordinators <br /> r: Donna K. Heran, R.E.H.S. Carl Bor man, R.E.H.S. <br /> Directo <br /> a r 600 East Main Street Borg <br /> man, <br /> California 95202 Mike Huggins, <br /> Margaret Lagoriorio, R.E.H.S.R.D.I. <br /> .H.S. <br /> �,•. �;:�• Laurie A.Cotulla, R.E.H.S. Telephone: (209)468 Fax: (209) 468-3433-3420 Robert McClellon R.E. <br /> 'FOR Assistant Director JetfO S <br /> APPLICATION FOR PERMIT TO CLOSE JUN 1 2 2008 <br /> UNDERGROUND STOPokGE TANX&STORING HAZARDOUS MATERIALkVIRUfVMENT HEALTH <br /> P'e` <br /> I. GENERAL INSTRUCTIONS: PERMIT/SERVICES <br /> Submit all information in triplicate. Answer all questions, leaving no blanks. One copy will be returned to the <br /> applicant with comments. <br /> 5 <br /> r—* 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, streets, <br /> 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 /> p ;p, ,3 ('QPo4r (�rr►��-+- s,.hnti-tF� 6-�{-og <br /> 3. Complete pages 3-6, "Application for Underground Storage Tank Closure Permit". Fot : Sampling firm shall <br /> (( be an independent third party from the contractor. <br /> 4. Complete page 9, "Authorization to Release". This form must be signed and dated by the <br /> OWNER/OPERATOR of the facility. <br /> 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 /> [/f 6. Complete all questions on page 10, the Environmental Health Department (EHD) "Underground Storage Tank <br /> Disposition Tracking Record",except those requiring a signature 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 /> "b n`' `� [►� 7. Submit a "Site Health&Safety Plan"as an addendum to this application,to address all potential hazards for this <br /> o—'-F— OB 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 <br /> h( �� County of San Joaquin Building Department and the incorporated City Building Departments, pursuant to the Uniform <br /> Building Code STD 70-11. (e. — "3 `d• <br /> 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to EHD approval of <br /> h the closure plan. <br /> [l� 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 /> hf <br /> f] 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> Pei C k'�4 <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 /> 7 See"III. SITE MITIGATION"on Page 2. <br /> EH 23 046 (Revised 12/31/07) 1 <br />