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BOARD OF TRUSTEES 52..rtl JOAQUIN LOCAL HEALTH DISwAICT SERVING <br />At Crow, Pres. San Joaquin County <br />Earl Pimentel, Vice Pres. 1601 East Hazelton Avenue City o1 Manteca <br />Tommy Joyce, Sec y. Stockton, California 95205 City of Manteca <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. <br />Daphne Shaw San Joaquin County 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 />1. ubmit 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 />(including water, sanitary sewer and storm sewer). <br />0Y 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />4. Complete the "Authorization to Release Analytical Data" form. <br />LIY5. Submit 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 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 />Elt 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. Appropriate advance <br />inspection notification of iurihffictional fire district is <br />contractor's responsibility. <br />❑ IO• bESCRIBE ME`J40b VSEO "To PURGE Tvktjk OFV14PD2S. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />Clinical Services <br />Environmental Health <br />Public Health Nursing <br />468-3400 <br />468-3830 <br />468-3420 <br />468-3860 <br />Air Pollution <br />Community Services <br />Laboratory <br />WIC <br />468-3470 <br />468-3820 <br />466-3460 <br />468-3280 <br />AIDS Information 469-3920 <br />