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/ BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTHI <br /> D STRICT SERVING <br /> '•Ai Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue city of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUN S MATERIALS <br /> � /,I. GENERAL INSTRUCTIONS: <br /> V0 Submit all information in triplicate. USE CARBONS. <br /> LK Z. Include a detailed site ma showingtank location and t e <br /> )iping, streets and adjacent propeties (north toward the ' <br /> op off the paged location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> / (including water, sanitary sewer and storm sewer) . <br /> b 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Data" form. <br /> 125. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> LJ 6. Procedures should e5cnlain decontamination techniques if <br /> applicable, materiails) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> Procedures should explain purging anti/or inerting method. <br /> !� 8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling protocol <br /> �- for Routine Tank Removals" for sampling criteria. <br /> G0 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Tank Disposition Tracking Record". The holder <br /> of the permit shall be res onsihle for ensuring that this form <br /> is completed and returned -he SJLHD. <br /> U' IO% The maximum review time for closure Plans is 15 working days <br /> �,� from the date of receipt of the adequately completed Plan. <br /> 10 1I. Advance ins ction notice of at least: 48 hours i <br /> V srautre� L <br /> e an oa uln Localt?a District. ro r>a e a vance <br /> ins ec ion notification o iuris_ is iona iredistrict is <br /> c > i i <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Servicos Environmental Health Public Health Nursing <br /> 468-3400 4E8-3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 468-3460 468-3250 <br /> ` AIDS Information 468-3620 . <br />