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AI Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. v 1601 East Hazelton Avenue V City of Manteca <br /> Tommy Joyce,Sac'y. 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.W. DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Malhews City of Ripon <br /> Thomas Schubert D.V.M. <br /> Daphne Shaw San Joaquin County <br /> - <br /> Harvey Williams,PRCity of StocktonD. San Joaquin County <br /> APPLICATION F'OR PERMIT TO CLOSIi <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I , GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and l'ypre, <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 I <br /> ( including water, sanitary sewer and storm sewer) . <br /> �3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> I <br /> I <br /> /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 responsibld party(ies) who will be disposing of <br /> waste generated on site. <br /> 7. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will tie obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> ❑ 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 aril returned the SJLHD. <br /> ❑ 9. Advance inspection notice of at least 48 hours is required by <br /> the San Joaouin Liacal Health District_Apropriate advance <br /> inspection notification of iurisTirtional fire district i <br /> contractor 's sibility <br /> I ' <br /> EH 23 040 <br /> REVISED 12/88 <br /> i <br /> I <br /> Administration Clinleal Services Environmental Health •Public Health Nursing <br /> 468-3400 488-3830 468-9420 488-9860 <br /> Nr Pollution Community Services Laboratory WIC <br /> 468-9470 468-3820 468-7460 4e8-ffi80 <br /> AIDS Information 468-3820 <br /> I <br />