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0 6 <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 /> UNDERGROUNS <br /> I. GENERAL INSTRUCTIONS: <br /> �l. Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> Mppiping, streets and adjacent properties (north toward the <br /> of the page) location of nearby septic tanks, <br /> leachfields, buiidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> la'3. Complete form "APPLICATION FOR PERMIT ICOR UNDERGROUND TANK <br /> CLOSURE". <br /> l 4. Complete the "Authorization to Release Analytical Data" form. <br /> U'5. Submit the apppropriate fees and complete the "Underground <br /> Tank Program I-'ee Worksheet". <br /> 0. 6. Procedures should explain 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 of <br /> waste generated on site. <br /> Q 7. Procedures should explain purging and/or inerting method. <br /> ET"'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 sampling criteria. <br /> [�'9. Complete the San Joaquin Local Health District's (SJLIID) <br /> "Underground 'Tank Disposition Tracking Record". The holder <br /> of thepermit shall be responsible for ensuring that: this formis completed and returned the SJLHD. <br /> EY 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> (J 11. Advance inspection notice of at least 48 hours is required hV <br /> L e an Juin-L,ocaT- ea i DisLrict. ro ria-e advance <br /> insDection notification o :jurisdictional tire district is <br /> contra ors response >> itv <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />