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11/02/2001 10:47 9166813 GEOFON INC PAGE 03 e. PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer 304 East Weber Avenue, Third Floor • Stockton, CA 95202 2091468-3420 APPLICATION FOR .710111 TO -CLOSE UNDERGROUND STORAGE TANKS STORING liiAZARDOUS MATERIALS I. GENERAL INSTRUCTIONS: 1 Submit all information in triplicate. Answer all questions, leaving no blanks. one copy will be returned to the applicantmith comments. 2. Include a detailed site map on a separate sheet of paper, showing the location of the taWcs(s), piping, (north to -ward the top of the page), nearby septic tanks, leachfields, water streets, adjacent properties wells, buildings, underground public utility lines (including water, sanitary sewer and r>tonn sewer), and distance of piping from tank to dispensers. if underground utilities are not included on the site snap, you must state in writing that USA Dig will be contacted prior to excavation activities. 3. complete page 3, "Application for Underground Storage Tank Closure Permit". of sampling firm shall be an indeRendent third art from the contractor. 4. Complete page 9, "Authorization to Release", This form must be signed and dated by the OWNERIOPERATOR of the facility. 5. Submit the appropriate fees and complete page 11, the "Underground Storage Tax& 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 be responsible for ensuring that this form Is and date of tart removal. The holder of the permit shall 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. 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 PIIS-FHD approval of the Closure plan. 10. The maximum review time for Closure Plans is 15 working days from receipt Of the adequately completed will be required with a S87.001hour fie and the plan. If gross deficiencies are identified, an addendum review will begin on the date of resubmittal. 11. Submit verification of the fire permit from the appropriate fire district at the removal inspection. 12, Advance inns notice of at. least 4$ hours is reouired py PHS-E14D. 13. Submit Contingency Plan for over,excavation at time of UST removal (if planning to over -excavate). See "Ill. SITE MITIGATION" on Page 2. EH 23 046 (Revised 09/21/00,1 Page I A Division of San Joaquin County Health coxe Services