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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres, 1601 EaSt Hazelton Avenue City of Manteca <br /> Stockton, California 95205 City of Escalon <br /> Tommy Joyce,Secy. City of Lodi <br /> James F.Culbertson <br /> John D.Most M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> City of Ripon <br /> Virginia Mathews <br /> Thomas SchubertD.V.M. � San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. 3 J A 7 San Joaquin County <br /> UNDEROUN APPLICATION FOR PERMIT TO CLOSE S MATERIALS <br /> CR <br /> I. GENERral�) <br /> TPJCPIONS: <br /> m <br /> [I U Submiinformation in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> top of the pae) location of nearby septic tanks, <br /> leabuL <br /> chfields, idirn3s and underground public utility lines <br /> (including water, sanitary s wer an storm sewer <br /> Com Wit fo mr 'AP�CATION OR P T FOR DERGROUND TANK t r <br /> CLO URE <br /> Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> scifv tthe responsoible narty(ies) who will b rlisnnsinq of <br /> Z/ —wasttefg n ns e. <br /> 7. Procedures should explain purging and/or inerting method. <br /> Describe in detail how soil and/or water samplesbeneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> ❑' 9. 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 /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11. Advance ins ction notice of at least 48 hours is re uired b <br /> L e an oa uta Local Healthis ricro ria e a vance <br /> in_s�ec�ion no i >ca ion o �urLs is tong ire district is <br /> contractor 'sronsibiliity. <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 Community Services Laboratory WIC <br /> 468.3470 468-3820 468-3460 46B-3280 <br />