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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, -M.D., �i.P.H., Health Officer <br /> '0—' East Weber Avenue, Third Floor - Stod<ton, CA 9520'2 <br /> L <br /> 209/468-3420 <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UN, DERGROUND STORAGE T.kNXS STORLNG HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> r1. Submit all information in triplicate. Answer all cuestions, leaving no blanks. One -coy will be returned <br /> to the applicant with comments. <br /> Include a detailed site map on a separate sheer of paper. showing the location of the tanks(s), piping, <br /> streets, adjacent properties(north toward the tot)of he page), nearby septic ranks, leachfields, water wells, <br /> buildings, ewer and storm.sewer} and distance <br /> underground public utility lines(inc;udingwarer, sanitary s e <br /> of piping from rank to dispensers. If underground utilities are act included on the site map, you must state <br /> in writing that USA Dig will be contacted prior to excavation activities. <br /> Complete page 33, "Application for Underground Storage Tank Closure Permit". <br /> J 4. Complete page 9, "Authorization to Release". This form must be signed and dared by the <br /> L <br /> OWNTRIOPERATOR of the facility. <br /> L Submit the appropriate fees and complete page 1.. the "Underground Storage Tank Program Fee <br /> Worksheet". <br /> F 6. Complete all questions on page 10, the Public Health Services-Environmental Health Division EHD) <br /> "Underground Storage Tank Disposition Tracking Record", except those requ=­ g a signature and date <br /> of rank removal. The holder of the permit shall be responsible ;or ensuring that this form is comrieed <br /> and returned to PHS-EHD within 30 days of the tank removai. <br /> 1, 7. Submit a "Site Health & Safety Plan" as an addendum to this apoii=ion. to address all potential <br /> hazards for this 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 recuired <br /> by the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11. <br /> 9. Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan. <br /> 10. 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 378.00/hour fee <br /> and the review will begin on the date of resubmittal. <br /> 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. <br /> 12. Advance inspection notice of at least 48 hours is reauired by PHS-EHD. <br /> EH 23 046 (Revised 9/11/96) Page I <br /> A Division of:an (oauuin Ciumv Hefltk Cire Services <br />