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0 <br />BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />Al 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.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 S MATERIALS <br />/11 GENERAL INSTRUCTIONS: <br />Submit all information in triplicate. USE CARBONS. <br />2. Include a detailed site map showing tank location and type, <br />. I np. streets and adjacent properties (north toward the <br />op off the page)location of nearby septic tanks, <br />leachfields, bur dings and underground public utility lines <br />�d <br />(including weaater anHary s weerr and storm sewe } , <br />3. Comp"let foriYt '� PLCATION FOR -�PERMIT UNDER� GRQU�I`iDTANK <br />��4. <br />CLOSURE" , i�jPBtC 5 S'��pg,/. <br />Complete the "Authorization to Release Analytical Data" form. <br />❑ 5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />2/6. Procedures should ex lain 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 o <br />waste nerated on site. � n Cr h � /4 � <br />7. rode ure h& " ecp fitWpurging and/or inerting methex]. <br />i} 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 satipling criteria. <br />9. Compplete the San Joaquin Local Health District's (SJLHD) <br />"Underground "Tank Disposition Tracking Record". The holder <br />ofthe permit shall. be respponsible 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 />11' Advance ins2gction notice of at least 48 hours is re uired b <br />' <br />'he Sar oa uin oda Aeath District. bra ria e a van <br />ins cion notification o oris is zona fire- iscT filets <br />Contractor's resoansi6iliTy. <br />EH 23 040 <br />REVISED 12/88 <br />,i- Y gat �-3390 <br />A,kd�o Cvl� <br />Administration <br />Clinical Services <br />468-3400 <br />468-3830 <br />Air Pollution <br />Community Services <br />468-3470 <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />