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�-�- le <br />PUBLIC HEALTH SERVICES <br />SA.L TC)AQl--L COL'ivT" <br />ENVIRONMENTAL HEALTH I?MS510N <br />Karen Furst, M.D., M.P.H., Health Officer <br />q ip;ja�� <br />304 East Weber Avenue, Third FIoor • Stockton, CA 95202 <br />2.09!468-3420 <br />,.OFOR PER�IIT�2CL0i�Iti <br />LSE GROLc'D STOR LGE T.-LN'K-; , T H- TS NLkTEPJALS <br />I. GENERAL IN3n, UCTIONS: <br />S°�amit a.,.IItor:natiot la triplicate, ArsT'eT all. questior s, leaving no blanks. Ore coot' xi11 bo-rerurned <br />to the applicant with ccrss:ents. <br />r } Incli de a detained site trap on a separate sheet of paper, showiz; the location of the to ks(s;, piping, <br />streets, adjacent proFerdes (north toward the top of the. page), nearby septic tanks, leachte:cls, water <br />wells, buildings, tmdergrouad public utility lines rinci id.ing water, s.,- tart' sewer a:.d storm sewer). and <br />distance of piping from tank :o dispensers. If ur_dergrotnd utilities are not included oft he Sita map, Ton <br />must state n writing that USA Lig will be contend prior to excavw.ior. actin ides, <br />i l 3. Ccmpiete page 3, "Application for UndergroLmd Storage Tarek Closure Permit".i� o : Samalina <br />Erm shall be an indeperdent chird oar:y from the contrctr- <br />i; <br />Complete page 9, "Authorization to Release". This forru =us; be signed and daccd by ;he <br />OW-XXOP£RATOR of the facilitly <br />j Submit the appropriate f�--:s and co=- I'= page 11, the 'Undarg Bund Storage Tank Pro;rn.•u Fee <br />Worlvtna". <br />t ; 6. Complete ail questions or page 10, the Piolic health Services-Er-vircnrneatal Health Division (P'r.S- <br />EHD) Underground Storage Tank. Disposition Tracicing Record", except t,.cse requiring a signature <br />and date of ta:c removal. The holder of ;he per7.ir shail be rnporsibie for ersurirg that this form is <br />complete : and returned :o PHS-i3HD within 30 days of the tan:{ ramval. <br />7. Submit a "Site Health & Safety Plan" as an addendu-n to this applicadcc. to address all potential <br />hazards for this speci:t: job site. Rzfer to the Site Safe ?!an Guida= Document for specifics. <br />[ ; <br />S. If facility is lo=cd outside of the city limits, submit a 'Bae'•,fill Excavation Certificate" as required by <br />he County of San Joaquin Buildia; Depari~:ent ar.d the incorporated Ciry Building Deaar-mcats, <br />pursuant to the Utuforn Building Code STD 70-11. <br />[ ; 9 Obtain a "Grading and Excavation Permit" :-on :he Cir: of Tracy Building Division prier to PtiS- <br />:HD approval of tl:e closure plan. <br />TIbe mat:tnutr. rniew :ire: far Closure plass is 15 working days from rcr-eip, of the adequately <br />cemxlcted Plast. If tress defciermies are identiSed, an addend:un will to requir_d with a $74.00 ho -r <br />fee and the review will beg:a or, the date of resubmittal. <br />Subtrst ve f.raticn of the fire permit from the apprcpriate fire district at the re.mral irspecdon. <br />,advance irst-ectmn recce Of It lean a hours cl reguired by Pl?S-EciD <br />1 13. Submit Contingency Man 'or fiver :,'*Cama:ie at crone of UST removal (if planning ov:--excavate), <br />See "11I. SITE %TIGATION" on P22 -e'2. <br />EH 3 046 (Revised 0&13;99) Page I <br />A ViIAZia-i o' San J-CagWR Coup:! Heai:h Car. Se:tiices <br />