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S 11 <br /> C-011 <br /> �OARO OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Ptmentel,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.Most 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 7 tC) -� UACcm.. City orton <br /> Harvey Williams,Ph.D. San Joaquu inn CCounty <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS ST�O'JRING HAZARDOUS MATERIALS <br /> I . GENERAL INSTRUCTIONS: � I �r o�J11 CH (To -ks tt"Vwd 6161") <br /> l`( 1. S It all information in triplicate. USE CARBONS. <br /> 2. 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 /> i(including water, sanitary sewer and storm sewer). <br /> EV 3. Complete form "APPLICATICHJ FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> i4. Complete the "Authorization to Release Analytical Data" form. <br /> < 'ubmit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 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 responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> C�/. /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 /> N8. /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 98 hours is required by <br /> the San Joaquin Local Health District. Appropriate advance <br /> inspection notification of jurisdictional fire district is <br /> contractor's responsibility. <br /> EH 23 090 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-9420 468.3880 <br /> Alt Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br />