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�tPI-RT.1c <br />CES SEALTH SE <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEAL�� 1�?;I��Q� <br />tt rea�th Officer <br />Ernest M. Fujimoto, M.D., <br />M.P,i <br />445 N. San Joaquin Street • P. O. Box 388 • Stockton. C 2 95201-0388 <br />209/4 3Ae 23cEt <br />L� <br />►=,,J lr9 <br />00,3 "y <br />GENERAL. INSTRUCTIONS: <br />Answer all questions, leaving no blanks. One copy will be <br />1. Submit all information in triplicate - <br />returned to the applicant with comments. <br />of the tanks(s), piping, <br />2. Include a detailed site map on a separate <br />sheet f of the shopagwing sept cn tanks, leachfields, water <br />streets, adjacent properties (north to he topr and storm sewer), <br />wells, buildings, underground public utility lines(including <br />water, <br />saare <br />nit sewe <br />dispensers. If } not included on the site <br />and distance of piping from tank to <br />map, you must state in writing that USA Dig will be contacted prior to excavation activities. <br />Colete age 3, "Application for Underground Tank Closure Permit". <br />mpp <br />This form must be signed and dated <br />4. Complete page 9, "Authorization to Release Analytical Data% <br />O,oVNER/OPERATOR of the facility. <br />by the <br />riate fees and complete page 11, the 'Underground Tank Program Fee Worksheet". <br />j, Submit the approp <br />nmental Health Division <br />6. complete lete all questions on page 10, the Public Health Services-Enviro <br />(PHS-EHD) "Unde around Storage Tank <br />Disposition <br />it ng shalRl ecobeesponsible, except tfor ensuringnhat <br />ssignature and date of tank removal The holder ofthe perm <br />this form is completed and returned to PHS-EHD within 30 days of the tank removal. <br />Plan" as an addendum to this application, to address all potential <br />7. Submit a "Site Health &Safety <br />Refer to the Site Safety Plan Guidance Document for specifics. <br />hazards for this specific job site. <br />8, If facility is located outside of the city limits, s nd the incoit a ll Excavation Cer-tiricate" as incorporated City Building Departmeired <br />nts, <br />by the County of San Joaquin Building Department <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 />receipt of <br />ely <br />10. The maximum review time for Closure Plaentified, an ais 15 ddend m vvg days ilitbe required twith aeSu8t00/hour <br />completed plan. If moss deficiencies are td <br />n on the date of resubmittal. <br />fee and the review will begi <br />11. Submit verification of the fire permit from.the appropriate fire district at the removal inspection. <br />12. <br />EH 23 007 (Revised 11/L92) <br />Page 1 <br />A Division of San Joaquin County Health Care Services <br />