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RECEIVED San Joaquin County SEP 2 8 2016 Environmental Health Department DIRECTOR Linda Turkatte, REI1 1 1868 E . Hazelton Avenue r � NTgL HEATH ,,a areas . . ,� Stockton , California 95205 =6232 ENVIR ® �� &T r% { , . . , Robert McClellon , REHS Website : www.sjgov . org/ehd Jeff carruesco , REHS , RDI Phone : (209) 468 -3420 Kasey Foley, REHS Fax : 209 464 -3433 Rodney Estrada , REHS Willy Ng , REHS APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT I . GENERAL INSTRUCTIONS : [ ] I . Submit all information in triplicate . Answer all questions , leaving no blanks . One copy will be returned to the applicant with comments . [ ] 2 . Include a detailed site map on a separate sheet of paper, showing the location of the tanks ( s) , piping , streets , adjacent properties ( north toward the top of the page) , nearby septic tanks , leachfields , water wells , buildings , underground public utility lines ( including water, sanitary sewer and storm sewer) , and distance of piping from tank to dispensers . If underground utilities are not included on the site map , you must state in writing that USA Dig will be contacted prior to excavation activities . [ ] 3 . Complete pages 3- 5 , "Application for Underground Storage Tank Closure Permit" . Not : Sampling firm shall be an independent third party from the contractor. [ ] 4 . Complete page 8 , "Authorization to Release" . This form must be signed and dated by the OWNER/OPERATOR of the facility . [ ] 5 . Submit a " Service Request" form with the appropriate fees , submit completed UPC forms for Facility and Tanks (formerly State A & B forms ) and complete the " Underground Storage Tank Program Fee Worksheet" . [ ] 6 . Complete all questions on page 9 , the Environmental Health Department ( EHD) " Underground Storage Tank Disposition Tracking Record " , except those requiring a signature and date of tank removal . The holder of the permit shall be responsible for ensuring that this form is completed and returned to EHD within 30 days of the tank removal . [ ] 7 . Submit a " Site Health & Safety Plan " as an addendum to this application , to address all potential hazards for this specific job site . Refer to the Site Safety Plan Guidance Document for specifics . [ ] 8 . If facility is located outside of the city limits , submit a " Backfill Excavation Certificate " as required by the County of San Joaquin Building Department and the incorporated City Building Departments , pursuant to the Uniform Building Code STD 70- 11 . j ] 9 . Obtain a "Grading and Excavation Permit" from the City of Tracy Building Division prior to the Environmental . Health Department ( EHD ) approval of the closure plan . [ ] 10 . The maximum review time for Closure Plans is 15 working days from receipt of the adequately completed plan . If gross deficiencies are identified , an addendum will be required with a $ 139 . 00/hour fee and the review will begin on the date of resubmittal . [ ] 11 . Submit verification of the fire permit from the appropriate fire district at the removal inspection . [ ] 12 . Advance inspection notice of at least 48 hours is required by EHD . [ ] 13 . If planning to over-excavate at time of UST removal , see " III . SITE MITIGATION " on Page 2 . Ei i 23 046 ( Revised 7/26/2016 ) I