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BOARD OF TRU <br /> Al Crow.Pres. STEES �..• <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> Earl Pimenlel,vice pre& SERVING <br /> TOMMY Joyce,sisey. 1601 East Hazelton Avenue San Joaquin County <br /> James F.Culbertson Stockton. California 95205 City of Manteca <br /> John D.Matt.M.D. JOGI KHANNA. M.D., M.P.H., DISTRICT HEALTH OFFICER City t of Lo <br /> alon <br /> Virginia Mathews City of Lodi <br /> Thomas Schubert,D.V.M. City of Tracy <br /> Daphne Shaw City of Ripon <br /> Harvey w118ams,Ph.D. San Joaquin County <br /> City of Stockton <br /> UNDERQ20UN APPLICATION FOR PERMIT TO CLOSE San Joaquin County <br /> n uws MATERIALS <br /> I• SAI INSTRUCTIONS: <br /> ❑ 1. Submit all information in triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed site map showing tank location and type <br /> lpp>pioyy, streeggts and adjacent properties (north toward the <br /> e a chfields�buildlocationdof nearby <br /> ear y septic tanksr <br /> (including water, sanitary sewer and stormnd sewer) . lines <br /> ❑ 3 CLOO UREte• form "APPLICATION FOR PERMIT FUR UNpERCROUND TANK <br /> 3S e <br /> ❑ 4. Complete the "Authorization to Release Analytical Data" form. <br /> ❑ 5 TannkPr09bmit thramp ropriate fees and complete the "Underground <br /> Fee Worksheet". <br /> ❑ 6. Procedures should exxpplain decontamination techniques if <br /> applir�ble, materials) utilized Eor rinsate, transportation <br /> an�dd/or sthe torage of hazardous waste generated on site, and <br /> waste generatedpOnssiite.�rty(ies) who will be disposing of <br /> ❑ 7. Procedures should explain Purging and/or inerting method. <br /> ❑ 8• Describe in detail how soil and/or water samples beneath the <br /> tank 's invert will be obtained. <br /> for Routine Tank Removals" for sRefer to "Sampling Protocol <br /> ampling criteria. <br /> ❑ 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> Uh ergrorndt7shall' beoreslonsiblekforr ensuring that holder of the pe p <br /> this <br /> is completed and returned the SJLHD. <br /> ❑ 10. The maximum review time forClosure Plans is 15 working days <br /> ❑ 11. <br /> from the date of receipt of the adequately completed Plan. <br /> Advance ins ction notice of at least 48 hours is re wired b <br /> f e an oa tln oca Rea <br /> insoec <br /> ,on no > tea ion o is Cr>c ro ria e a ranee <br /> mor actor rs st o nsi 1 ]uris ilona ire >s ric >s <br /> EH 23 040 <br /> REVISED 12/88 <br /> AUG 16 1990 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Administration Clinical Services <br /> 468-3400 Environmental Health <br /> 468-J830 Public Health Nursing <br /> Air Pollution Comm468-3420 <br /> 468-3470 unity Services 468-39G0 <br /> 460-3820 Laboratory <br /> 468-3460 W11— <br /> AIDS <br /> ICAIDS Information 468-3820 468-3280 <br />