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p <br /> BOARD OF TRUSTEES SAN JOAQUIN LOC L HEALTH DIST41T SERVING <br /> k Al Crow,Pres N San Joaquin County <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton,California 95205 Cly of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mnst 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 STORAGE, TANKS STORING HAZARDOUS MATERIALS <br /> I . GENERAL. INSTRUCTIONS: <br /> �711. Sutxnit all information in triplicate. USE CARBONS. <br /> iU 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, buildings, 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". r <br /> C] 14 Complete the "Authorization to Release Analytical Data" form. <br /> 5 Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 6. Procedures should explain decontamination techniques if <br /> applicable, material(s) 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 /> 4Describe 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 /> B. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holden <br /> of the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> 9. Advance inspection notice of at least 48 hours is required by _4_3 75 <br /> the San Joaquin Local Hearth District. Appropriate advance <br /> insl2gction notification of Jurisdictional fire district is <br /> contractor 's responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Emlronmental H"hh Public Health Nursing <br /> 468-3400 468»3830 468.3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> a <br />