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r a� <br /> e <br /> O.#RD OF'TRUSTEES A JOAQUIN LOCAL &JALI Df � <br /> � .,��CT � SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Ptmentet,Vice Pres. <br /> 1601 East Hazelton Avenue <br /> i, <br /> e , Tommy Joyce,SecCity of Manteca <br /> Secy. Stockton;California 95205 try of Manteca <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. 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 5hew - f,� ] C 7 City of Stockton <br /> Harvey Williams,Ph.D. C/ I l�G� �Z tt1 San Joaquin County <br /> 1 i <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. I <br /> 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 />'4 (including water, sanitary sewer and storm .sewer) . <br /> Ltd 3. Complete form "APPLICATION FOR PERMIT- P T FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical D�ta" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> [1-6. Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site;l and <br /> specify the responsible party(les) who will be disposing of <br /> waste generated on site. <br /> E�/7. Describe in detail how soil and/or water samples beneath the <br />' tank's invert will be obtained. Refer to "SamplingJProtocol <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 SJLHD. <br /> 9. Advance insipection notice of at least 48 hours is rglgui=ed by <br /> the San-Joaquin Local: Health District. Appropriate' advance <br /> inspection notification of jurisdictional fire district is <br /> contractor.'s responsibility. <br /> i/iv )-I e-rhoci i�c <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 488-3830 _ 468-3420 468-3860 <br /> Air Pollution munity Services laboratory WIC <br /> 488-347--10-' D 468-3820 46a-3460 468-3280 <br /> AIDS Information 468-3820 <br />