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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin CountyEarl 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.VirginJOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Thom ie Mathews City of Ripon <br /> Thomas Schubert,D.V.M. <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,PhCity of Stockton <br /> San San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND�a`I�fF�GE�'�{�$�Tbft1'l�fG-FfA'L7�TF[50pS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> ✓ tw <br /> 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 /> e3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> VJ j Complete the "Authorization to Release Analytical Data" form. <br /> GS. Submit the appropriate fees and complete the "Underground <br /> J� Tank Program Fee Worksheet". <br /> 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 responsible party(ies) who will be disposing of <br /> waste generated on site. 110,,j,J,L_L �c101 Ci _ . <br /> 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 /> 619. Compplete 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 /> J110. The maximum review time for Closure Plans is 15 working days <br /> �(J from the date of receipt of the adequately completed Plan. <br /> F ] 11. Advance inspection notice of at least 98 hours is required b <br /> e an oa uin Localea is ric ro ria e a vance <br /> insgec ion no i ice ion o Juris is iona ire is r>c is <br /> contractor �S res Dons>.TiTi v <br /> EH 23 090 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 <br /> 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 <br /> 468-3280 <br /> AIDS Information 468-3820 <br />