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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton,California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.N., 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 STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> W / <br /> � 1. Submit all information in triplicate. USE CARBONS. <br /> Ld 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 /> LY 3. Complete form "APPLICATION F'OR PERMIT FOR UNDERGROUND TANK / <br /> CLOSURE". <br /> U�d 4.. Complete the "Authorization to Release Analytical Data" form. <br /> Ui 5. Submit the appropriate fees and complete the "Underground <br /> kank Program Fee Worksheet". <br /> lyl i Procedures should explain decontamination techniques if <br /> l ) applicable, material(s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the responsiblcl party(ies) who will be disposing of <br /> / waste generated on site. <br /> 7. scribe 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 SJLHD. <br /> ❑ 9. Advance inspection notice of at least 48 hours is required by <br /> the San Joaouin Local Health District_ Appropriate advance <br /> cection notification of iurihdictional fire district is <br /> contractor's responsibility <br /> JZ <br /> IO- DESCRIBE ME`THO b USED TO PURGE TV tjV- OF VAPo2S. <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 CemmunM/Services Laboratory WIC <br /> 468-3470 I ! 468-3820 468-3460 468-3280 <br />