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_ OAHO OF TRUSTEES *AN JOAQUIN LOCAL HEALTHtSTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Plmentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Selly. Stockton, California 95205 Clty of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Most,M.D. _ JOGI KHANNA. M.D., M.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews - n City of Ripon <br /> Thomas Schubert,D.V.M. j 6 ^ San Joaquin CountyDaphne Shaw � '%X'/�(/!/�/y City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS l <br /> �1 <br /> I . GENERAL INSTRUCTIONS: CZ <br /> / /P�. <br /> (�' 1rInclude <br /> all information in triplicate. USE BONS. <br /> a detailed site map showing tank location and type, <br /> ppng, streets and adjacent properties (north toward the <br /> top of the page), location of nearby septic tanks, <br /> leachfields, buildings, and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> �3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> L�d 9�omplete the "Authorization to Release Analytical Data" form. <br /> LTJKt the appropriate fees and complete the "Underground <br /> Program Fee Worksheet". <br /> dures should explain decontamination techniques if <br /> cable, material(s) utilized for rinsate, transportation <br /> an /or storage of hazardous waste generated on site, and <br /> specify the responsibld party(ies) who will be disposing of <br /> Zowaste generated on site. <br /> pescribe 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 /> l] 8. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> 9. Advance inspection notice of at least 48 hours is rPauired by <br /> the San Joaquin Local Health District_Ap�r�pri<atF advance <br /> inspection noti.fication of iuri?sdictional Eire district is <br /> contractor 's responsibility. <br /> L1 10, I`IcTl+up Us . � —ro I�UQer IANC <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration - Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468.3420 468-3860 - <br /> Air Pollution Community Services Laboratory WIC _. <br /> 468-3470 468-3820 468-3460 468.3280 <br /> AIDS Information 488.382n <br />