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1 da�ie,4C � <br /> PUBLIC HEALTH SERVICES <br /> U4&,'N <br /> SAN JOAQUIN COUNTYjWI KHANNA MU N1 P HHealth Officer P O Box 2009 • (160t East liuclton Avenue) • Stockton. California 9520i <br /> (209) 468 3400 AFCEIVED <br /> APPLICATION FOR PERMTr TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING IIAZARDOUS MATER3ALS CT 2 2 1992 <br /> GENERAL INSTRUCTIONS' ENVIRONMENTAL HEALTH <br /> PERMIT/S�RVCCES <br /> [ ] 1 Submit all Information in triplicate Answer all questions, leaving no blanks One copy wi 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 Complete page 3, "Application for Underground Tank Closure Permit" <br />' [ ] 4 Complete page 9, 'Authori78tion to Release Analytical Data" This form must be signed and dated <br /> by the OWNER/OPERATOR of the facility. <br /> [ ] 5 Submit the appropriate fees and complete page 11,the"Underground Tank Program Fee Worksheet'. <br /> ( ] 6 Complete all questions on page 10, the Public Health Services-Environmental Health Division <br />' (PHS-EHD) 'Underground Storage Tank Disposition Tracking Record', except those requiring a <br /> signature and date of tank removal The holder of the permit shall be responsible for ensuring that <br /> this form is completed and returned to PHS-EHD within 30 days of the tank removal <br />' ( ] 7 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 the Site Safety Plan Guidance Document for specifics <br />' [ ] 8 if facility is located outside of the city limits, submit a "Backfill Excavation Certificate" as required <br /> by the County of San Joaquin Building Department and the incorporated City Building Departments, <br /> pursuant to the Uniform Building Code STD 70-11 <br /> [ ] 9. Obtain a `Grading and Excavation Permit' from the City of Tracy Building Division prior to PHS- <br /> EHD approval of the closure plan <br /> ( J 10. The maximum review time for Closure Plans is 15 working days front receipt of the adequately <br /> completed plan If gross deficiencies are Identified,an addendum will be required with a $53 00/hour <br /> fee and the review will begin on the date of resubmittal <br /> ( ] <br /> 11 Submit verification of the fire permit from the appropriate Ore district at the removal Inspection. <br /> [ ] 12 Advance Inspection notice of at least 48 hours Is required by PHS-EHD. <br /> EH 23 007 (Revised 7/10/92) Page 1 <br /> A Divisinn of sin Joaquin(ounry Ficilth(yrc ScrvicCs <br />