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k0 D 00 TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br />AI Crow, Pres <br />Earl Plmentel, Vice Pres 1601 East Hazelton Avenue <br />Tommy Joyce, Secy. Stockton, California 95205 <br />James F. Culbertson <br />John D. Mast, M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />'GOUNIs�`APPLICATION FOR PERMIT TO CLOSE <br />�.�i'iST�AZ�� S MATER I ALS <br />GENERAL INSTRUCTIONS: <br />I. Submit all information in triplicate. USE CARBONS. <br />2. Include a detailed site map showing tank location and type, <br />p1ping, streets and adjacent properties (north toward the <br />opo the page)location of nearby septic tanks, <br />leachfields, bui�din7s and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />4. Complete the "Authorization to Release Analytical Data" form. <br />Submit the appropriate fees and complete the "Underground <br />,Tank Program Fee Worksheet". <br />Procedures should explain decontamination techniques if <br />1/applicable, inaterial(s) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />//"specify the responsible party(ies) who will be disposing of <br />waste generated on site. <br />Procedures should explain purging and/or inerting method. <br />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 />9.' Compplete the San Joaquin Focal Health District's (SJLHD) <br />"Undergroun3 'Tank Disposition Tracking Record". The holder <br />of the permit shall. be res t� onsible for ensuring that this form <br />is completed and returned Che SJLHD. <br />0. The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Pian. <br />1. Addv-ann-ceins Dectionn^^n-o-tt-i-�cte�—of at least 48 hours is required by <br />1;he c� tl JCk3Cillln r.n(-aI HP.a 1 IIZ:�It- nnrnnr�.a ea �r�nr..� <br />EH 23 040 <br />REVISED 12/88 <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <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 />Administration <br />Clinical Services <br />Environmental Health <br />Public Health Nursing <br />468-3400 <br />468-3830 <br />468-3420 <br />468-3860 <br />Air Pollution <br />Community Services <br />Laboratory <br />WIC <br />468-3470 <br />468-3820 <br />468-3460 <br />468-3280 <br />AIDS Information 468-3820 <br />