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BOARD OF TRUSTEES SJOAQUIN LOCAL HEALTH DISI T SERVING <br /> AlV�' <br /> Crow,Pres. San Joaquin County <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> Jamt.. F.Culbertson City of Lodi <br /> J;lin D.Mast,M.D. JOG[ KHANNA, M.D., M.P.H., 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 FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> ]_. Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and t e <br /> iping, streets and adjacent properties north tow yp JUN of the page) location ofnearbyseptic tanks and the JL11V 1g 0 <br /> leachfields, F�uifdinrls and undergroundpublicutility lines <br /> (including water, sani(ary sewer and storm sewer) . ENVIR0r+MENTAL HEALP <br /> 3. ComEElete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK pFRMlT!SFR)'"('" <br /> CLO LJRE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> Z 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet", <br /> 6. Procedures should ex lain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> � p 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 /> 7, rocedures should explain purging and/or inerting method. <br /> scribe in detail how soil and/or water samples beneath the <br /> ank's invert will be obtained. Refer to "Sampling Protocol <br /> Vo 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 (late of receipt of the adequately completed Plan. <br /> ❑ 11. Advance inspection notice of at least 48 hours is reguuil d by <br /> Lii'anoacuin Lorca- ea Is ric ro r1�"ate advance <br /> ins.-pec—Elon noti r�'ca ion-o - "suras is lona ire is ric is <br /> ConCrac--or 's responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3660 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />