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H. b. (�0107 <br />BOARD OF TRUSTEES <br />At Crow, Pres. <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce. Secy. <br />James F. Culbertson <br />John D. Mast M.D. <br />Virginia Mathews <br />Thomas Schubert D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D, <br />0. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.O., M.P.H., DISTRICT HEALTH OFFICER <br />APPLICATION• PERMIT TO CLOSE <br />•,7i•t•• • ••T \�' i• 1 •MIN le• m• <br />I. GENERAL INSTRUCTIONS: <br />L <br />W20. <br />Submit all information in triplicate. USE CARBONS. Include a detailed site map showing tank location and 'type, <br />pipincl, streets and adjacent properties (north toward the <br />1top 0 the page) location of nearby septic tanks, <br />leachfields, buildings and underground public utility lines <br />C K (including water, sanitary sewer and storm sewer). <br />3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE" <br />$. Completd"'the <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 />Sri .._ <br />"Authorization to Release Analytical Data" form. <br />5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet" <br />nn f <br />Procedures should explain decontamination techniques if <br />applicable, Inaterial(s) utilized for rinsate, transportation <br />an 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 />NU -7. Procedures should explain purging and/or inerting method. <br />8. 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 Colete the San Joaquin Local Health District's (SJLHD) <br />"Undmperground '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 />❑ 1.1. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3030 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468.3280 <br />