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f < <w <br />PUBLI01 <br />�0. <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. Bos 388 f Stockton. CA 95201-0388 <br />209/468-3420 ,. - 0P/X <br />GENERAL INSTRUCTIONS: <br />(] L Submit all information in triplicate. Answer all questions, Ieaving no blanks. One copy will be <br />returned to the applicant with comments. <br />(� 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br />streets, adjacent properties (north toward the top of the page), nearby septic tanks, leachfields, water <br />wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br />and distance of piping from tank to dispensers. If underground utilities are not included on the site <br />map, you must state in writing that USA Dig will be contacted prior to excavation activities. <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 OWNERIOPERATOR of the facility. <br />S. <br />Submit the appropriate fees and complete page 11, the "Underground Tank Program Fee Worksheet". <br />6. <br />Complete all questions on page 10, the Public Health Services -Environmental Health Division <br />"Underground Storage Tank Disposition Tracking Record", except those requiring a <br />(PHS-EHD) <br />signature and date of tank removal. The holder of the permit shall be responsible for ensuring that <br />30 days of the tank removal. <br />this form is completed and returned to PHS-EHD wig <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 />�' (] 8. <br />If facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required <br />Department and the incorporated City Building Departments, <br />by the County of San Joaquin Building <br />pursuant to the Uniform Building Code STD 70-11. <br />(] 9. <br />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. <br />Tice maximum review time for Closure Plans is 15 working days from receipt of the adequately <br />If deficiencies are identified, an addendum will be required with a 578.00/hour <br />completed plan. gross <br />fee and the review will begin on the date of resubmittaL <br />(] 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 48 hours is reouired by PHS-EHD. <br />fiH 23 007 <br />(Revised 11/1'92) Page 1 <br />A Division of San Joaquin County Health Care -Services <br />