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y <br /> '+BOARD OF TRUSTEES SAN OAQUIN LOCAL HEALTH DISTRO SERVING <br /> Al Craw,Pros. *115 ,'J /////� San Joaquin County <br /> Earl Pimenfel,vice Pres. 16o East Haze/ -�{ r/ �l .Ciof Esc eca <br /> Tommy Joyce,Secy. StOCktOn, Calif ( / // �S�/� r' S'of Escalon <br /> James F.Culbertson /// City of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. A cam' San Joaquin County I <br /> /� <br /> Daphne Shaw �J.J /"\ V Jl��r_J l" City of Stockton <br /> Harvey Williams,Ph.D. rrn� <br /> APPLICATION FOR PERMIT TO CLOSE D �MY <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERI 0 <br /> MAR 91989 <br /> I . GENERAL INSTRUCTIONS: ENVIRONMENTAL HEALTH iN <br /> PERMIT/SERVICES <br /> 2/1. Submit all information in triplicate. USE CARBONS. <br /> i <br />' <br /> 52. 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, N, <br /> leachfields, buildings, and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> !J 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK F <br /> CLOSURE". <br /> ❑ 4. Complete the "Authorization to Release Analytical Data" form. <br /> (� 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". , ¢ /aO L- <br /> T 7 <br /> ( 6. Procedures should explain decontamination techniques if x <br /> applicable, material(s) utilized for rinsate, transportation 4" <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. SP Q --44 !/ <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. IH <br /> 8. Complete the San Joaquin Local Health District's (SJLHD) Kr <br /> "Underground Tank Disposition Tracking Record". The holder e <br /> of the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> IIJ J9. Advance inspection notice of at least 48 hours is required by <br /> `/ the San Joaquin Luca]. Health District_ n ro riate advance a <br /> pL F—_ <br /> inspection notification of jurisdictional fire district is <br /> contractor's respon;:;ibility, <br /> tr7. lo. ttc icor) <br /> EH '23 040 <br /> REVISED 12/89 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 . <br /> Air Pollution Community Services laboratory WIC <br /> 468-3470 469-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />