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t \ <br /> JS p <br /> 10.0 OF Tr Sli, IOAQUIN LOCAL HEALTH DIS' _ CT SERVING <br /> PiY 7 San Joaquin County <br /> 1601 East Hazelton Avenue Ci of Manteca <br /> .„mmy Joyce.Secy Stockton, California 95205 City of Facalon <br /> James F.Culbertson T o �p �(ti Cly of Lodi <br /> John D.Mast M.D. k G- JOGI KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews O ` City of Ripon <br /> Thomas Schubert D.V.M. �Y k• Sen Joaquin County <br /> Daphne Shaw ae City of Stockton <br /> Harvey Williams,Ph.D. 0o v San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> 2/1-. Submit all information in triplicate. USE CARBONS. <br /> Ind 2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the V/ <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 /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK / <br /> CLOSURE". <br /> 5Er'4. Complete the "Authorization to Release Analytical Data" form. <br /> Er5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 0'6. 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 /> U 7. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> e TanK <br /> `� (a 8. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> aaPbv%tea) is the permit <br /> tash returned responsible for ensuring that this form <br /> com <br /> ted <br /> 9. Advance inspection notice of at least 98 hours is required by <br /> the San Joaquin Local Health District. ApQrMriate advance <br /> inspection notification of jurisdictional fire district is <br /> contractor's responsibility. <br /> q IO. Mood used to Iner�' -t'F�-ta.r-tk. ' <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-9830 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 />