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a 0 <br />BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />At Crow, Pres. San Joaquin County <br />Earl Pimentel, Vice Pres. 1601 East Hazelton Avenue City of Manteca <br />Tommy Joyce, Secy. Stockton, California 95205 City of Escalon <br />James F. Culbertson City of Lodi <br />John D. Mast M.D. JOGI KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER City of Tracy <br />Virginia Mathews City of Ripon <br />Thomas Schubert D.V.M. San Joaquin County <br />Daphne Shaw City of Stockton <br />Harvey Williams, Ph.D. San Joaquin County <br />APPLICATION POR PERMIT TO CLOSE <br />UNDERGROUNISFFAGB S MATERIALS <br />� I1./. GENERAL INSTRUCTIONS: <br />Ll Y- Submit all information in triplicate. USE CARBONS. <br />'q . . <br />�� 2. Include a detailed site map showing tank location and type , <br />nc, streets and adjacent properties (north toward the <br />'op of{ the page) location of nearby septic tanks, <br />leachfields, bulidings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />2'3. Complete form "APPLICATION FOR PERMIT POR UNDERGROUND TANK <br />CLOSURE" <br />1 t t e "A thori tion to Release Analytical Data" form. <br />� u. n . <br />5. Submi the approp ate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />Procedures should explain decontamination techniques if <br />applicable, material(s) utilized for rinsate, transportation <br />an 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 />a 77 Procedures should explain purging and/or inerting method. <br />L 8. 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 and 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 />❑�2] Advance ins ction notice of at least 48 hours is re uired by <br />the an oaquin oca hea is ric ppropria e a Vance <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 />460-3620 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3620 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3360 <br />WIC <br />468.3280 <br />