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SERVING <br /> BOAR <br /> BOA€O OF TRUSTEES SAOAQUIN LOCAL HEALTH DIS i ,T San Joaquin County <br /> Al Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,Vice Pres. <br /> Stockton, California 95205 city of Escalon <br /> Tommy Joyce,Sec'y. City of Lodi <br /> James F.Culbertson Ci of Trac <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City <br /> City of Ripon <br /> Virginia Mathews _ San Joaquin County <br /> Thomas Schubert,D.V.M. r- y} �y City of Stockton <br /> Daphne Shaw / ?/ 1 r t / San Joaquin County <br /> Harvey Williams,Ph.D. f <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> [l 1. Submit all information in triplicate. USE CARBONS. <br /> Eh/ 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 /> [IJ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> ly 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 /> f <br /> C 7. 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 /> 8. 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 /> LJ" 9. Advance insp2ction notice of at least 48 hours is reguired_ b <br /> the San Joaruin Local Heiate advance <br /> inspection notification of jurisdictional fire district is <br /> contractor's responsibility_. <br /> Lid I t7• Me ttn o d :+ <br /> r 'I-az r7 kL <br /> M t� <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3.400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br /> Ar <br />