Laserfiche WebLink
IL,E <br /> pr TRUSTEES SAN JOAQU I N C3UNTY <br /> BOARD PUBLIC HEALTH SERVICES <br /> AI Grow,Pres ENVIRONMENTAL HEALTH D r V I�I ON r SERVING <br /> Earl Plmentel,Vice Pres, F,� � an <br /> RX 2009� SJoaquin County <br /> Tommy Joyce,Secy. City u Manteca <br /> James F.Culbertson STGCKTCii`!a CA ?5S 1 City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Dodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.b. City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGRO s MATERrALs <br /> I GROZAL INSTRUCTIONS: <br /> Submit all information in triplicate.F USE CARBONS, <br /> �. Include a detailed site map showing tank location and type, <br /> iping, streets and adjacent properties (north toward the <br /> op o the paged location of nearby septic tanks <br /> leachfields, bulidin(Js and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> + 3. Com lete form "APPLICATION FOR p <br /> CLOSURE "• ERMIT feOR UNDERGROUND TANK <br /> jv - C 4. Complete the "Authorization to Release Analytical Data" form. <br /> CIO'~ 5• Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> Procedures should el1 lain decontamination techniques if <br /> p" GQ3{( as/orastoragetof hazardottslwastefor <br /> generatedeontsite,and ion <br /> sastepecs y theatedponsibte,party(ies) who will be disposing of <br /> c Procedures should explainur - <br /> p ging and/or xnerting method. <br /> 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 /> Complete the San Joaquin Local Health District's <br /> Underground Tank Disposition Tracking Record". TheLholder <br /> of the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD.' <br /> D/1110. The maximum review time for Closure <br /> Plans i <br /> from the date of receipt of the adequatelys 15 working days <br /> completed pian. <br /> 11. Advance ins ction notice of at least 48 hours is re aired b <br /> ENE an oa ut n ocaI=F{ea is ric oro rla e a vanca <br /> ins ec ion no z lqa ion o , uric ir_ lona ireis .r1C is <br /> COn aC or SrLS�on51 <br /> EH 23 040 <br /> REVISED /$g <br /> A vLLC-4 p t. re+� hae.Qac� +a <br /> 4 <br /> Ir1atp <br /> Administration Clinical Services <br /> 4.68-3400468-3630 Environmemal Health Public He3l!h Nursing <br /> 468-3420 <br /> -�� 468-3860 <br /> Air Pollution Community Services — <br /> 468-347© 468-3820 Laboratory WIC <br /> 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />