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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br />AI Crow, Pres. <br />Earl Plmenterl, vice Pres. <br />1601 East Hazelton Avenue <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />James F. Culbertson <br />John D. Mast M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />APPLICATION FOR PERMIT TO CLOSE <br />a P' !' e a e't•'Ce1�lY:1�' • •h I O d• <br />—/I. GENERAL INSTRUCTIONS: <br />71111. Submit all information in triplicate. USE CARBONS. <br />E--2. Include a detailed site map showing tank location and type, <br />piping, streets and adjacentproperties(north toward the <br />top of the page� location of nearby septic tanks, <br />leachfields, but�dirn3s and underground public utility lines <br />�� (including water, sanitary sewer and storm sewer). <br />L7 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />// <br />CLOSURE". <br />Ia 4 Complete the "Authorization to Release Analytical Data" form. <br />(5. Submit the appFropriate fees and complete the "Underground <br />_ Tank Program ee Worksheet". <br />6. Procedures should explain decontamination techniques if <br />applicable, Iwterial(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 />7 Procedures should explain purging anti/or inerting method. <br />lid' e. 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 />9. 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, alai returned the SJLHD. <br />❑ 10. The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />❑ 11. advance inspection notice of at least 411 hnurs is rarniirPA by <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3030 <br />Community Services <br />4611-3820 <br />Environmental Health <br />468.3420 <br />nine i.,,,,.._......_ .m nom.. <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 />468-3960 <br />WIC <br />468.3280 <br />