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WILLIAM B. WALKER, M.D.
HAZARDOUS MATERIALS PROGRAMS
HEALTH SERVICES DIRECTOR
4585 Pacheco Boulevard
Martinez, California
94553-2233
Ph (925) 335-3200
Fax (925) 646-2073
RANDALL L. SAWYER,
CHIEF ENVIRONMENTAL HEALTH AND
HAZARDOUS MATERIALS OFFICER
SR#________________
APPLICATION FOR PERMIT TO CLOSE
UNDERGROUND STORAGE TANK SYSTEMS
(office use only)
 REMOVAL
 CLOSURE IN PLACE
 TEMPORARY CLOSURE
FACILITY INFORMATION
Contact:
Site ID #
Facility Name:
Address
Cross Street
Owner/Operator
Phone #
Phone #
Phone #
CONTRACTOR INFORMATION
Contractor Name
Address
Contractor Email:
Insurer
Fire District
Laboratory Name
Sampling Firm
Phone #
CA License #
Contractor Fax:
Worker
Comp ##
Permit
County
Class
Phone #
Phone #
TANK INFORMATION
Tank
ID #
Tank Size
Contents
Install
Date
Removal/Closure
in Place Fee
$1798.00 +
385.00
385.00
385.00
385.00
385.00
Temp
Closure Fee
$771.00 +
128.00
128.00
128.00
128.00
128.00
Applicants must perform all work in accordance with Contra Costa County Ordinances, State and Federal laws
and regulations of Contra Costa Health Services Hazardous Materials Programs. Owner or licensed agents
signature certifies the following: “I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in such a manner as to become subject to worker’s compensation laws of
California.” Contractor’s hiring or subcontracting signature certifies the following: “I certify that in the
performance of the work for which this permit is issued, I shall employ persons subject to Worker’s
Compensation Laws of California.”
Applicant’s Signature _______________________Title _____________
 APPROVED
 APPROVED WITH CONDITIONS
(see attached conditions)
PLAN REVIEWER’S NAME_________________________________
Date_______
 DISAPPROVED
DATE_________________
Any deviations from this application must be submitted to CCHS Hazardous Materials Programs prior to commencing
work.
• Contra Costa Alcohol and Other Drugs Abuse Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health • Contra Costa Health Plan •
• Contra Costa Hazardous Materials Programs • Contra Costa Mental Health • Contra Costa Public Health • Contra Costa Regional Medical Center • Contra Costa Health Centers •
1.
2.
3.
4.
5.
6.
7.
8.
9.
Is the current certificate of worker’s compensation insurance on file?
Does the contractor possess a “Hazardous Substance Removal Certificate”?
Has everyone on site, including crane/backhoe operator, has been certified to
work on a hazardous waste site in accordance with Title 8 CCR?
Has a “Site Specific Health & Safety Plan” for this job site been submitted?
Has the contractor obtained approval from the local fire department to
perform tank cutting?
Is there knowledge or evidence of leakage from the tank(s) and/or piping?
If yes, please explain:
_____________________________________________________
_____________________________________________________
If tank residual exists, identify transporting hazardous waste hauler:
Name:___________________________ Hauler Registration #:_______
Address:____________________City:____________State:______
Phone: ___________________________
Decontamination Procedures:
a. Will tank(s) and piping be decontaminated prior to removal?
b. Identify contractor performing decontamination:
Name:
Address:
City:
State:
Zip: _________Phone#:
______________
c. Describe the method(s) to be used for decontamination:__________
________________________________________________
________________________________________________
________________________________________________
d. Describe how rinsate material will be stored onsite prior to
manifesting offsite:___________________________________
________________________________________________
________________________________________________
e. Rinsate Hauler and Permitted Treatment, Storage & Disposal Facility:
Name:_________________Hauler Registration #: ___________
Address:_______________ City: __________ State: ___
Phone#: _______________
Permitted Disposal Site:________________________________
Describe
the method(s) utilized to purge and/or inert the tank(s):
a.
________________________________________________
________________________________________________
b. Tank/Piping Hauler:
Name: _______________________________________
Address: ______________________________________
City:
____ State:_____
Phone#:_________________
Hauler Registration # (if hauled as hazardous waste): ___________
 YES
 YES
 NO
 NO
 YES
 YES
 YES
 NO
 NO
 NO
 YES
 NO
 YES
 NO
Tank/Piping Disposal Site:
Name: _______________________________________
Address: ______________________________________
City:
____ State:_____
Phone#:_________________
EPA ID # (if transported to a permitted facility): ______________
Is the sampling firm an independent third party from the contractor?
 YES
a. Describe in detail, how the soil and/or water sample(s) beneath the tank and
piping will be obtained:
________________________________________________
________________________________________________
________________________________________________
Describe how the excavation will be backfilled with suitable material upon
removal: ________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
c.
10.
11.
12.
Handling of excavated soil:
a. What material will be used to line the tank pit and cover the stockpile?
_________________________________________________
b.
13.
14.
What will be the final destination of the excavated stockpile?
_________________________________________________
c. Contaminated Soil Hazardous Waste Hauler:
Name:_________________Hauler Registration #: ___________
Address:_______________ City: __________ State: ___
Phone#: _______________
Depth to groundwater?_________________________________
Source of groundwater information________________________
Indicate the responsible party to be billed for additional CCHSHMP staff time
expended beyond 3 hours minimum permit payment per tank. If the party
designated below is different than the permit applicant, e.g. property owner, the
party must acknowledge this responsibility for the billing by signature and date
below.
Name:________________________
Mailing Address:___________________________________________
Daytime Phone:_____________________
Signature:_____________________ Title:______________ Date:_____
This Underground Storage Tank Closure Permit expires three (3)
months from the date of application approval.
 NO