Laserfiche WebLink
BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Sec'y. Stockton, California City of Manteca <br /> James F.Culbertson City or Escalon <br /> John D.Most M.D. JOGI KHANNA, M.D., M.P.H., 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,Ph.D. City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> 40 . <br /> I 2. Include a detailed site map showing tank location and t �, <br /> YIx piping, ti- <br /> streets and adjacent properties (north toward the <br /> top of the page), location of nearby septic tanks, ly <br /> leachfields, buildings, and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 01 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> @Y' 4. Complete the "Authorization to Release Analytical Data" form. <br /> 0115. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> IS 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 /> v <br /> 7. Describe in detail how soil and/or water sample: beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> �i for Routine Tank Removals" for sampling criteria. <br /> Ll 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 -arid returned the SJLHD. <br /> 9. Advance inspection notice of at least 48 hours is rPouired by <br /> the San Joiouin Local Health District_Ap�rgpriate advance <br /> rnspection notiN,ication of iurp'=-dictional fire district is <br /> c000ntractor— 's i soonsibility <br /> �. DESccIaE >RtccEDVAE To Rt usQD TD INERT YA.b2S lk UCrsT <br /> EH 23 040 <br /> REVISED 12/88 <br /> A mii issttrr�n Clinical Services Environmental Health •Public Health Nursing <br /> 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 <br /> 4fi8.3280 <br /> AIDS Information 468-3820 <br />