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BOARD OF TRUSTEES SANSIOAAUIN LOCAL HEALTH DISTFilur SERVING <br /> AI Crow,Pres. <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue San Joaquin county <br /> Tommy Joyce,sec'y. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. City of Lodi <br /> JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews , <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 Cf OSE <br /> UNDERGROUND [PING HAZARDOUS MATERIALS <br /> 1. GENERAL INSTRUCTIONS: <br /> ❑ <br /> I. Submit all information in triplicate. USE CARBONS. <br /> AR/2. 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 <br /> leachfields, buiidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLO URE". <br /> [ 4. Complete the "Authorization to Release Analytical Data" form. <br /> pw}}-5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, materials) 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 /> E 7. Procedures should explain purging and/or inerting method.el <br /> 8. Describe in detail how soil and/or water samples beneath the RR�v <br /> tank's inv rt will be obtained. Refer to ''Sampling Protocol <br /> ,�, // for Rou a Tank Removals" for sampling criteria. <br /> X7'9. COMSIete 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 /> K 0. 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 ins action noticeof at least 48 hours is re wired b <br /> e San oa in oca ea > r>cAppropriate advance <br /> inspec ion no i ica ion o Jurisdictionalire is ric is <br /> contractor s resoonsibili v <br /> EH 23 040 <br /> REVISED 12/88 <br /> 1 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 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />