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9 0 <br />BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br />AI Crow, Pres. <br />Earl Pimentel, Vice Pres. 1601 East Hazelton Avenue <br />Tommy Joyce, Sec'y. Stockton, California 95205 <br />James F. Culbertson <br />John D. Mast, M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROS MATERIALS <br />INSTRUCTIONS: <br />Submit all information in triplicate. USE CARBONS. <br />2. Include a detailed site map showing tank location and type, <br />ppiping, streets and adjacent properties (north toward the <br />top of the pa e) location of nearby septic tanks, <br />(7,K leachfields, buildings and underground public utility lines <br />(in luding water, sanitary sewer and storm sewer). <br />3. mplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />OSURE". <br />Complete the eei <br />thori���zatin to Release Analytical Data" form. <br />❑ 5. Submit theAd�ppriate fees and complete the "Underground <br />nk Program Worksheet". <br />6, ocedures should ex lain decontamination techniques if <br />applicable, materials) utilized for rinsate, transportation <br />and/or 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 />7. Procedures should explain purging and/or inerting method. <br />8. Describe in detail how soil and/or water samples beneath the <br />ank's invert will be obtained. Refer to "Sampling Protocol <br />or Routine Tank Removals" for sampling criteria. <br />9. Compplete the San Joaquin Local Health District's (S <br />"Underground Tank Disposition Tracking Record". Th <br />of. the rmit shall. be responsible for ensuring th <br />is comp eta and returned the SJLHD. foc,lC Low <br />�d Cu L e nZ c r <l Y-77 4 7�X--c/%z--- <br />❑ 10. The maximum review time for Closure Plarag is 15 wor <br />from the date of receipt of the adequately complete <br />❑ 11. <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 />JLHD) <br />e holder <br />t this form, <br />,eA"-tcC- SrCc. 5t <br />king days <br />d Plan. <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 />460-3820 <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 />