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Vf 1^uaI«1 J%._,, dVMVVIIv LVbNL 11CML11-1 UIJ1�l•1 SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City o1 Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. <br /> Daphne Shaw San Joaquin County Harvey Williams,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> , GENERAL INSTRUCTIONS: <br /> . Submit all information in triplicate. USE CARBONS. <br /> 12. 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 /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> LV 9. Complete the "Authorization to Release Analytical Data" form. <br /> 0 . Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <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 be 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 and returned the SJLHD. <br /> ❑ 9. Advance inspection notice of at least 48 hours is required by <br /> the San Joaquin Local Health Distrigt_ApQropriate advance <br /> inspection notification of iu iAlctional 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 468-3880 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />