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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pres. SERVING <br /> Earl PimentN.Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,PhD. City of Stockton <br /> San Joaquin Count' <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANGS STORING HAZARDOUS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> I. 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 t11e <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 /> NJ 3, Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Tata" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> nl 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 /> \1D <br /> waste generated on site. <br /> `1I 7• Describe in detail how soil and/or water samplestxyneath 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 1cti <br /> 0AQ on notice of at ]aw t qg hours 1 rPnnrred by <br /> the an Joaquin Lcx.a] tl alth s <br /> —L-Ri _ ro riate vane <br /> !gntLatton notificationrtior ] fired>it rpt is <br /> contras reinn ty <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services <br /> 468-3400 Environmental HeaNh <br /> Public Health Nursing <br /> _ h♦'"afviffw. t wFnIM tlN �M�""i <br />