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BOARD OF TRUSTEES SAft JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimemel,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. JOG[ 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 /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS JJ�� <br /> I. GENERAL INSTRUCTIONS: p g awv jo <br /> 0--T. Submit all information in triplicate. USE CARBONS. MAR 1989 VV <br /> QST Include a detailed site map showing tank location and t�EMRjSERVICESITH <br /> piping, streets and adjacent properties (north toward the <br /> top of the page), location of nearby septic tanks, <br /> leachfields, buildings, and undergroTd public utility lines <br /> (including water, sanitary sewer and'storm sewer) . <br /> Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> El--4Complete the "Authorization to Release Analytical Data" form. <br /> 0-5. Submit the appropriate fees and complete the "Underground <br /> / Tank Program Fee Worksheet". <br /> L�Y6. Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the responsibld party(ies) who will be disposing of <br /> waste generated on site. <br /> 5--I' 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 /> 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 /> 91--9� Advance inspection notice of at least 48 hours is required by <br /> the San Joaauin Local Health District. �XpRropriate advance <br /> inspection notification of iu il.d'ictional fire district is <br /> contractor's responsibility. <br /> hefl�oct L)St<r) 4-ri Pure tA&jk <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 466-3820 468-3460 468-3280 <br /> AIDS Information 4RR-382n <br />