Laserfiche WebLink
BOARD OF TRUSTEES SAN JOAQUIN 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.H., 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 /> UNDERGIR S MATERIALS <br /> 1 I. GENERAL INSTRUCTIONS: <br /> !J 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 /> op 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 /> �3 Compplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> VComplete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> W6.) <br /> Tank Program Fee Worksheet". <br /> 6. Procedures should explain decontamination techniques if <br /> ap licable, materials) utilized for rinsate, transportation <br /> a /or storage of hazardous waste generated on site, and <br /> �' t}e specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> I✓s 7. Procedures should explain purging and/or inerting method. <br /> E�1. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> or Routine Tank Removals" for sampling criteria. <br /> Ek`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 iced b <br /> e an oa >n oca eaDistrict. ro ria e a vance <br /> inspgction notification or Jurisdictionalire district is <br /> con rac or s responsibility. <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 468-3280 <br /> AIDS Information 468-3820 <br />