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BOARD OF TRUSTEES SAN J©AQUIN LOCAL HEA�i DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue Clty of Manteca <br /> Tommy Joyce,Secy. Stockton,California 95205 City of Escalon <br /> James F.Culbertson <br /> City of Lodi <br /> John 0.Mpstath M.D. JOGI KHANNA, M.D., M.P.H.. DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Schubert,D.V.M. <br /> Daphne Shaw San Joaquin County Harvey Williams,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I . GENAL INSTRUCTIONS: <br /> L/l. Submit all information in triplicate. USE CARBONS. <br /> Ibd 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". <br /> ❑�/4ZComplete the "Authorization to Release Ana " <br /> 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(les) who will be disposing of <br /> waste generated on site. <br /> `f" . 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 SJLHrD. <br /> CV <br /> 9. Advance inspection notice of at least 48 hours is required b <br /> the San Jos uin Local Health District. Appropriate advance <br /> ins ction notification of Jurisdictional fire district is <br /> contractor's responsibility. <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 yyiC <br />