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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTHICT SERVING <br /> At Crow,Pres, <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. City of Manteca <br /> Stockton. California 95205 <br /> James F.Culbertson City of Escalon <br /> John D.Mast M.D. JOG[ KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> • San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> LIT 1. Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, <br /> piping, 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 /> L� 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> L9�9. Complete the "Authorization to Release Analytical Data" form. <br /> LH 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> Ld 6. 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 /> 7. 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 /> 0. 8. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> ./ j Op _l of the permit shall be responsible for ensuring that this form <br /> ty 0 is completed and returned the SJLHD. <br /> 0 9. Advance inspection notice of at least 48 hours is required by <br /> the San Joaquin Local Health District. �Np2ropriate advance <br /> inspection notification of jurihd'irtional fire district is <br /> contractor 's resgonsibility. <br /> IU. NE7t+oc� Use b Tu <br /> p l,c>r TANK OF VAPORS <br /> EH 23 090 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air PollutionCommunity Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS 1Mprmntinn 4nn.a99n <br />