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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. Sen Joaquin County <br /> Earl Plmentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Selly, Stockton, California 95205 Cly of Escalon <br /> James F.Culbertson Cly of Lodi <br /> John D.Mast.M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> ThomVirgina Mathews <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County Harvey Williams.,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROIJN S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate, USE CARBONS. <br /> O 2. Include a detailed site map showing tank location and type, <br /> piping, streetsandadjacent properties (north toward the <br /> tleachfields, ulidin stiandoundergroundppib tanks <br /> 3. g public utility lines <br /> (including water, sanHary sewer and storm sewer) . <br /> 131f3' Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> C�/ CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> 61/5. Submit the appFropriate fees and complete the "Underground <br /> / Tank Program ee Worksheet". <br /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> /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 /> ❑ Procedures should explain purging and/or inerting method. <br /> scribe 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 /> 9. 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 /> The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> 11. Advance inspection notice of at least 98 hours is re aired b <br /> L e an os. uin LocalFlea s r c ro ria e a vane <br /> insuec ion <br /> notification of Jurfs lC ions. ire 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 468-3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 468-3460 468-3280 <br />