Laserfiche WebLink
ARD 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 Jnyce,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.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M. City or Ripon <br /> San Joaquin County <br /> Daphne Shaw - q <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUNI�FEA�TAF�ICS—WQMNU-FlAZmbms MATERIALS <br /> I. ENERAL. INSTRUCTIONS: <br /> 13'-1. ubmit all information in triplicate. USE CARBONS. <br /> ET�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 tanksr <br /> leachEields, uL�dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> — /CLOSURE". <br /> ra4 Complete the "Authorization to Release Analytical Data" form. <br /> I.Y 5. Submit the appropriate fees and complete the "Underground <br /> ank Program Fee Worksheet". <br /> 21.6-. 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 /> aste generated on site. <br /> [;e - . Procedures should explain purging and/or inerting method. <br /> E;-4- 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 /> L] 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> /f��/� o I�ahegpreormatTank <br /> sha111beorespion onsTblekfo9 ensurang that thisform holder <br /> s 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 /> 11 Advance ins ction notice of at least 48 hours is re wired by <br /> Fue-san oajuin oEa ea Lstric ro ria e5uvance <br /> W cion no i ica ion o -turfs is iona ire is rict is <br /> con rac or s resDOu>i TETEY <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health <br /> Public Health Nursing <br /> 468-3400 468-3830 <br /> 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory <br /> 468.3470 468-3820 WIC <br /> 468-3460 468-3280 <br /> Amp fnfnrmnrinn eco neon <br />