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• a• rh; • 1tl•1:: l$:,ZI�iLHitl' P� 1 y <br />J I. GENERAL INSTRUCTIONS: <br />l� 1. Submit all information in tri icate, USE CARBONS. <br />M a K.t I vwat.e. - eu c! <br />[ 2. Include a detailed si a map showing tank location and type, <br />pipinelg, streets and adlacent properties (north toward the <br />top off the pa e)loca ion of nearby septic tanks <br />leachfields, ui dings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />I, 4. Complete the "Authorization to Release Analytical Data" form. <br />;1,5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />El 6. Procedures should explain decontamination techniques if <br />applicable, materials) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />specify the responsible party(les) who will be disposing of <br />waste generated on site. <br />FO <br />Procedures should explain purging and/or inerting method. <br />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 />CJ <br />S. 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 anNl 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 />EH 23 040 <br />REVISED 12/88 <br />Administratlon <br />468-3400 <br />Air Pollution <br />468.3470 <br />Clinical Services <br />468-3030 <br />Community Services <br />460-3820 <br />Envlronmen!al Health <br />468-3420 <br />AIDS Information 468-3620 <br />Laboratory <br />468-3460 <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />Public Health Nursing <br />468-3860 <br />WIC <br />468.3280 <br />BOARD OF TRUSTEES <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />AI Crow, Pres. <br />Earl Plmentel, vice Pres. <br />1601 East Hazelton Avenue <br />Tommy Joyce, Sec'y. <br />Stockton, Cellfornla 95205 <br />James F. Culbertson <br />John D. Mast, M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Virginla Mathews ` <br />Thomas Schubert, D,v.M. <br />Daphne Shaw I <br />Hervey Williams, Ph.D. <br />• a• rh; • 1tl•1:: l$:,ZI�iLHitl' P� 1 y <br />J I. GENERAL INSTRUCTIONS: <br />l� 1. Submit all information in tri icate, USE CARBONS. <br />M a K.t I vwat.e. - eu c! <br />[ 2. Include a detailed si a map showing tank location and type, <br />pipinelg, streets and adlacent properties (north toward the <br />top off the pa e)loca ion of nearby septic tanks <br />leachfields, ui dings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />I, 4. Complete the "Authorization to Release Analytical Data" form. <br />;1,5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />El 6. Procedures should explain decontamination techniques if <br />applicable, materials) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />specify the responsible party(les) who will be disposing of <br />waste generated on site. <br />FO <br />Procedures should explain purging and/or inerting method. <br />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 />CJ <br />S. 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 anNl 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 />EH 23 040 <br />REVISED 12/88 <br />Administratlon <br />468-3400 <br />Air Pollution <br />468.3470 <br />Clinical Services <br />468-3030 <br />Community Services <br />460-3820 <br />Envlronmen!al Health <br />468-3420 <br />AIDS Information 468-3620 <br />Laboratory <br />468-3460 <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />Public Health Nursing <br />468-3860 <br />WIC <br />468.3280 <br />