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BOARIJ OF TRUSTEES SAS! �AQUIN LOCAL HEALTH. L1!STRIS.0110 SERVING <br /> Crow.Pres. San Joaquin County <br /> `Ea::Pir„ectoi,Vice Pr es. 160' Cast Hazelton Avenue S %L City of Manteca <br /> Tommy Joyce,Sac'y. S'..ockton, California 95205 v City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHP.NNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. ,( 1 San Joaquin County <br /> Daphne Shaw / GJ J� Us��.�M sc fo cn, City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County r. <br /> APPLICATION FOR PERMIT TO CLOSE ��u��� <br /> I�tDERGROlIN7��T�Gt�TA1JK�i,S'T`U[21��A-'IARZSbOS MATERIA_ <br /> GENERAL INSTRUCTIONS: JUN 20 1989 <br /> 1 Submit all information in triplicate. USE CAREONS . <br /> ENVIRONMENTAL HEALTH^ {fit 2. Include a detailed site map showing tank location and t vpe PERMIT/SERVICES <br /> pipincj, streets and adjacent properties (north toward the <br /> op or the page) location of nearby sc-ptic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> '�3. mplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> V4 . <br /> . Complete the "AuthcriraCion to Release. Analytical Data" form. <br /> ❑ 5. Submit the appropriate fees and complete thev"Underground <br /> Tank.. Program Pee WorksheeC". <br /> CiQProcedures sl,olild explain decontamination techniques i? <br /> applicable, materials) utilized for rinsat:e, transportation <br /> an ;or stora e of hazardous wa:3Le generated on site, and <br /> r, r f th< eon Jf 'c ;:artv( ies) who will be disposing of <br /> _Prccei.,ures should n:.Dlalin ruiq_ng and/or _nert: Inq lnetnod. <br /> +� 8. Xscr Lbe in detail hG',r soi.I and/oi_ water Samples be-neath the <br /> ,tank 's invert will be- obtained. Refer to "Sal;pling Protocol <br /> for Routine Tank Removal_:" for sampling criteria . <br /> e.-9. Complete the "an Joaquin Local Health District's (SJLHD) <br /> "Unaerground 'Tank Disposition Tracking Record" . The holder <br /> l;>f the permit shall be res,punsible for c,nsur.ing that this form/ <br /> is completed ar;d returned the SJLHD. <br /> Yl <br /> [ /0. The Iwiximtun 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 48 hours is rewired by <br /> E le .aS n Joa uin 'Loca ea LSiI's r Lc��_pprol r late advance <br /> inspection noti_>ca ion c)[—urisclictional fire districE is <br /> con n=.^f r-=r resi�onsilJiL.1 <br /> - --- -- <br /> EH 23 040 <br /> REVISED 12/88 <br /> ff F -SGT S/ 14P <br /> D Copy OF .inB "'71o,.; <br /> ❑ VJ M F✓7i r0.. F J, ��c!.'Grr.�r�^ •°` .�t5✓�d%L <br /> 1"f <br /> Administration Clinical Services Ewv onmental Health Public Health Nursing <br /> 468-3400 SEE-3530 465-3420 468-3860 <br /> Air Pollution Community Serai�,s Lauorntory WIC <br /> 468-3470 468-3820 468-:3-;50 468-3280 <br /> ✓• ?,f7�dT AiG:. Irdorr,aaan ,i;iC-:?v?.0 - . <br />