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I7, sfv, <br /> ;3.0.480 OF TRUSTEES SAN JOAIQUIN LOCAL HEALTH DISTRit., I � SERVING <br /> At Crow,Pres. 0.0.0.JJJ San Joaquin County <br /> Ead PirnenW.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.Mas!,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. n San Joaquin County <br /> Daphne Shaw l� 0 (Y� 7��f ��S' pj y}�j City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PLIC;MIT TO CLOSE X �� U$d J-4 <br /> UNDERGROUN7JI=MTTANKS 5'1`OI?1 TIEIAAMIMS MATERIALS <br /> GENERAL INSTRUCI'IONS: Vcmawltb <br /> Submit all information in triplicate. USE CAR <br /> IF9' 2. Include a detailed site map showing tank location aRAYt 5,1989 <br /> pipingq, streets and adjacent properties (north toward tfie <br /> top of the page) location of nearby septic tan�uVIR NMEfyIAhHEALTH <br /> leachfields, buildings and underground public a 10011T CES <br /> // (including water, sanitary sewer and storm sewer) . <br /> G✓ 3. Complete form "APPLICATIONOR PERMIT FOR UNDERGROUND TANK KiAD Of r),�a%'NE <br /> C 1,05URE"• roaedQs i=.a.Q►�cM-9 �-eaA4,v w <br /> 4/ Complete the "Author i.zation to Release Analytical Data" form. <br /> 5. Submit the appropriate fees sand compleLe the "Underground <br /> Tank Program Fee Worksheet" . <br /> IJ 6. Procedures should explain decontamination techniques if <br /> apr)licable, 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. <br /> �7. Procedures should explain purging and/or inert::ing method. <br /> Y/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. Com. lete 'the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record" . The holier <br /> of the permit shall. be responsible for ensuring that: this form <br /> is completed and returned the SJLI-ID. <br /> ❑ 10. 't'he maximum review time for Closure Plans is 15 workinq days <br /> from the date of receipt of the adequately completed Pian. <br /> ❑ 1' Advance insDec:tion notice of. at `least 48 hours iis�re�uir-ed by <br /> the San oac��u��i.n l_ t Ei ltii:lricE:A ro riate ae9vance <br /> ins x:0.ton notiF O-'alnn uT—tori icElona rirc ci`s ricE_t;_ <br /> con actoDrT res �n: :tht <br /> L---Y_ <br /> EH 23 040 <br /> REVISED 12/88 <br /> �] T iPi", Z)1-,:r- <br /> Administration <br /> !n5_r <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 />