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( ] I. <br />PUBLIiCEALTH S <br />�o�°��`!••.c <br />(OGi K'%.kN .i MD. `l.P K. <br />P.O. Box 2009 • (1601 East Hazelton :venue) • Stockton, California 95201 <br />(209) 468-3400 <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS NtATERLALS <br />GE:VER.-kL. INSTR UCTIO KS: <br />Submit all information in triplicate. One copy is returned to the applicant with comments. <br />[ J 2. Include a detailed site map, on a separate sheet of paper, showing tank location and type, piping, <br />streets and adjacent properties (north toward the top of the page), location of the nearby septic tanks, <br />leacht3elds,wells, buildings, under, ound public utility lines (including water, sanitarl server and storm <br />server), and distance of piping from tank to dispensers. <br />(J 3. Complete page 3, *Application for Under, round Tank Closure Permit'. <br />( J 4. Complete page 9, 'Authorization to Release Analytical Data'. <br />[ J 5. Submit the appropriate fees and complete page 11. the "Undergmund Tank Program Fee Worksheet". <br />(J 6. Describe on pages 4 & 5 the decontamination techniques if applicable, material(s) utilized for rinsate, <br />transportation and/or storage of hazardous waste generated on site, and specify the responsible <br />party(les) who will be disposing of waste generated on site. <br />[ ] 7. Desc;;be on page 5 the method for purging and/or inerting tanks) and piping. <br />(J S. Descnbe on pace 5 in detail how soil and/or water samples beneath the tank(s) and piping will be <br />obtained. <br />() 9. Complete the pertinent secvioa of page 10, the Public Health Services -Environmental Health Division <br />(PHS-EIT-M) 'Underground Tank Disposition Tracking Record'. The holder of the permit shall be <br />responsible for ensuring that this form is completed and returned to PHS-EHD. <br />(] 10. Submit a "Site Health & Safety Plan', as an addendum to this application, to address all potential <br />hazards for this specific job site. Refer to Site Safety Plan Guidance Document for specifics. <br />[ J 11. Submit a "Compaction Report' as required by the County of San Joaquin Building Department and <br />it's incorporated City Building Departments, pursuant to the Uniform Building Code STD 70-1. <br />(j 12. Obtain a 'Grading and Mxc avation Permit' from the City of Tracy Building Division prior to PHS- <br />EHD approval of the closure plan. <br />(j U. The ma dmum 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 S53.00/hour <br />fee and the review will begin on the date of resubmittal. <br />[ J 14. Submit verification of the fire permit from the appropriate fire district (prior to scheduling removal <br />inspection). <br />[ j 15. Advance inspection notice of at least 48 hours is reouired by Public Health Services. <br />Page 1 <br />A C)Mu t nt San Joaquin Canty Health r_WC Setwtcs <br />