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BOARD OF TRUSTEES 9)IrN JOAQUIN LOCAL HEALTH DIS-AICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 Cly 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. /��o (,'L�/ San Joaquin CountyDaphne Shaw �� a/ �1 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> pA 1. Submit 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 /> 2/3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". NLoe,� 3+d par 1� ,S atnp IC r <br /> U/4. Complee,to the "Authorization to Release Analytical Data" form. <br /> A // lU i th ;7" <br /> OYJ 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> [a/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 /> Ga 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 /> 1'r 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 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 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 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 />