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a. • <br />It <br />PUBLICISHEALTH <br />SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br />445 N. San Joaquin Street • P. O. Box 388 • Stockton, CA 95201-0388 <br />209/468-3420 ;� <br />( ? <br />a <br />GENERAL INSTRUCTIONS: <br />(j 1. <br />Submit all information to triplicate. Answer all questions, leaving no blanks. One copy will be <br />returned to the applicant with comments. <br />2. <br />Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br />toward the top of the page), nearby septic tanks, leachfields, water <br />streets, adjacent properties (north <br />wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br />included on the site <br />and distance of piping from tank to dispensers. If underground utilities are not <br />that USA Dig will be contacted prior to excavation activities. <br />map, you must state in writing <br />. 3. <br />Complete page 3, "Application for Underground Tank Closure Permit". <br />4. <br />Complete page 9, "Authorization to Release Analytical Data". This form must be signed and dated <br />by the OWNER/OPERATOR of the facility. <br />5. <br />Submit the appropriate fees and complete page 11, the "Unde around Tank Program Fee Worksheet". <br />it 6. <br />Complete all questions on page 10, the Public Health Services -Environmental Health Division <br />Tank Disposition Tracking Record", except those requiring a <br />f' <br />(PHS-EHD) "Underground Storage that <br />and date ofd removal. The holde r of the pbe <br />lof tank <br />hresponsible <br />signature removal.euring <br />01 days <br />this form is complete and returned to PHS EHD within 3k <br />7. <br />Submit a "Site Health & Safety Plan" as an addendum to this application, to address all potential <br />Plan Guidance Document for specifics. <br />hazards for this specific job site. Refer to the Site Safety <br />1 j 8. <br />If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required <br />incorporated City Building Departments, <br />by the County of San Joaquin Building Department and the <br />pursuant to the Uniform Building Code STD 70-11. <br />N j 9. <br />Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to PHS- <br />_ ` <br />EHD approval of the closure plan. <br />(j 10. <br />The maximum review time for Closure Plans is 15o from <br />will receipt equi f the a ae� ately our <br />addendum <br />completed plan. If gross deficiencies are identified, <br />fee and the review will begin on the date of resubmittal. <br />(j 11. <br />Submit verification of the fire permit from.the appropriate fire district at the removal inspection. <br />12. <br />Advance inspection notice of at least 43 hours is re uired by PHS-EHD. <br />EH 23 007 <br />(Revised 11/1/92) Page 1 <br />A Division of San Joaquin County Health Care Services <br />