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BOARD OF TRUSTEES SA JOAQUIN LOCAL HEALTH DISTa...c:T SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Mantecay. Stockton, California 95205 City of Escalon <br /> Tommy Joyce,Sec <br /> James F.Culbertson City of Lodi <br /> John 0.Mast,M.O. 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 /> UNDERGROUND 97U=Z—TA K S MATE R I ALS <br /> GENERAL INSTRUCTIONS: <br /> 1. Submit all information In triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed site map showing tank location and tyype, <br /> piping, streets and adjacent properties (north toward tFie <br /> top of the paye)) location of nearby septic tanks <br /> leachflelds, bui�dings and underground public utility lines <br /> �� (including water, sanifary sewer and storm sewer) . <br /> '�/ ❑' Complete/ form " PLI TION IPOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". f'Ua ka-66-1 ai r a"Pter <br /> Ind" Complete the "Authorization & Release Analytical Data" form. <br /> ltd 5. Submit the appropriate fees and complete the "Underground <br /> 'Tank Program F'ee Worksheet". ' <br /> ❑ 6. Procedures should ex lain decontamination techniques if <br /> applicable, Inaterial(s) utilized For rinsate, transportation <br /> at�d/or storage of hazardous waste generated on site and <br /> specify the responsible party(ies) who will be disposing of <br /> CU'/7 <br /> „ � waste generated on site. !1/4u1- lticl �u(3ah_: 4� 1 ),�/�SN,.� <br /> I-U' 77 Procedures should explain purging arxi/or inerting method. <br /> 0 Ze. Describe in detail how soil and/or water samples beneath the <br /> tank's Invert will be obtained. Refer to "Sampling Protocol <br /> Eir/ for Routine Tank Removals” for sampling criteria. <br /> 9 Complete the San Joaquin Local Health District's (SJLHD <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of the permit shall be resvonsible for ensuring that this form <br /> is completed a►xl returned the SJLHD. <br /> ❑ 10. The maximum review time for Closure Plans Is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11. Advance ins tion notice of at least 48 hours is re uired by <br /> Me San JoaQuin Loca ea > DisErict. ADDrooriate advance <br /> ins ec ion no i ica on oL -jurisdictional tire district is <br /> con rac .or s responsibility. <br /> EH 23 040 <br /> REVISED 12/86 <br /> S P-14-4Q-1-1 <br /> 0 <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 /> 777,yr, <br />