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' 'BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> At Crew,Pres. SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMTT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS 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 /> 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 /> Ipr 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> 0-5. Submit the appropriate fees and complete the "Underground <br /> Tank Program roe Worksheet". <br /> 6-6. Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the responsibld party(ies) who will be disposing of <br /> waste generated on site. <br /> tYr 7. 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" or Sam ling criteria. eO tee E <br /> oY U� e F ZAl e L �& S-r�6v�.e <br /> E�`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 /> CY 9. Advance inspection notice of at least 48 hours is renuired by <br /> the San Joaquin Local H1!a1th D1strict_Aopriate advance <br /> inspection notification of iurihd-ir•tiortal fire district is <br /> �lV•\'I[ ,j contractor 's responsibility. 1/ <br /> r0• D65LRIB¢ IN ne7NOp Us ib to INk'ZT -rAMK Ld lee. AOL- / LE <br /> EH 23 040 4 —7c-� pepfS� ��`� /�j6„gL, I�x10 /"E <br /> REVISED 12/88 Ake (,�t l9A4 �!a'�,dj ,Eu (/!i?e F.ohpL /TILL 1510 <br /> GJl t L �Jc / E f�� r6Q..J F.W/r�2 ora✓ed/zvC. <br /> Administration Clinical Services Environmental Health <br /> 468-3400 468-3830 468-3420 Public Health Nursing <br /> 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 466-3820 468-3460 <br /> 4fi0-3280 <br /> AIDS Information 4611.'11120 <br />