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BOARD OF TRUSTEES <br />Al Crow, Pres. <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce, Secy. <br />James F. Culbertson <br />John D. Most M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />C� y <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUN�E S MATERIALS <br />I. GENERAL INSTRUCTIONS: <br />1. Submit all information in triplicate. USE CARBONS. <br />2. Include a detailed site map showing tank location and type, <br />bipinc�{, streets and adjacent properties (north toward the <br />op 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 />�1 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />® 4. Complete the "Authorization to Release 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 />andlicable,meto ihazas)utilized for rinsede, transportation <br />specify the responsible party(ies)gwho will be disposing of <br />waste generated on site. <br />❑ 7. <br />❑ 8. <br />❑ 9. <br />❑ 10. <br />❑ 11. <br />Procedures should explain purging and/or inerting method. <br />Describe in detail how soil and/or water samples beneath the <br />tanks 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 (SJLHDj <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 SJLHD. <br />The maximum review time for Closlire Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />SERVING <br />San Joaquh% County <br />City of Manteca <br />City of Escaion <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />a: <br />Administration Clinical Services Environmental Health <br />468-3400 468-3030 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 460-3820 408-3460 <br />AIDS Inrnrma+ion 4RA-1P1)0 <br />�Y 1 <br />Public Health Nursing } <br />468-3860 i <br />Wlv i <br />466-3280 <br />