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nunnu u, rnuarcw Jit�i�h✓t�rn w...r�� rr�r,�rrr urJ�ra�r J hvinlG <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel.Vice Pres. 1601 East Hazelton Avenue Cly 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. 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 <br /> City of Stockton <br /> Harvey Williams,Ph.D. / San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> p,s 1. Submit all information in triplicate. USE CARBONS. <br /> 49 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 /> W3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". �/e� 3hc� �a r S le r - 7, f �d t� <br /> �fJy,, „��,,� n w>� � s � <br /> IiJ' 9. ComQl to the "Ruthqrization to Releas Analytical for>Q.��QS i3sfmc <br /> rf%, 3h�!p4.i Yzj S[l�iyrP/e/ neo` c�w� <br /> 03J '5. Submit the appropr``ffate fees and complete the "Underground <br /> �//� Tank Program Fee Worksheet". <br /> EW 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 /> Lia 7. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> �f/� for Routine Tank Removals" for sampling criteria. <br /> LTJ 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 /> CeI9. Advance inspection notice of at least 48 hours is required by <br /> the San Joaouin Local Health District. Appropriate advance <br /> inspection notification of iurisdictional fire district is <br /> contractor's responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 488-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br /> :;2^.imvsr'R.aarwa.^.mas.�r�. +rl&-.4*x4ax7 r.€-'n.m�..i,��z . :..• ,a . -...� �. .."_:'�-. .tis. . �.._ +`:'s�:'.<'e'�:"°�s"s.��,u�r f""' .�r'. � .�`�if � <br />