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�D a P,C� <br />BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT - SERVING <br />San Joaquin County <br />Al crow, Pres. 1601 East Hazelton Avenue City of Manteca <br />Earl Plmentel, Vice Pres. Ci of Escalon <br />Tommy Joyce, Sec'y. Stockton, California 95205 City <br />of Lodi <br />James F. Culbertson <br />John D. Mast M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />City of Ripon <br />Vlrpinia Mathews <br />San Joaquin Count' <br />Thomas Schubert D.V.M. <br />Daphne Shaw oof Stockton <br />a <br />J <br />Harvey Williams, Ph.D. San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDER OU E1DMO�—S MATERIALS <br />GENERAL INSTRUCTIONS: <br />. Submit all information in triplicate. USE CARBONS. <br />T--25. Includea detailed site map showing tank location and type, <br />piping, streets and adjacentproperties(north toward the <br />top of the pagged location of nearby septic tanks <br />leachfieldsI buildings and underground public utility lines <br />(including water, sanifary sewer and storm sewer). <br />2"3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />4. Complete the "Authorization to Release Analytical Data" form. <br />C1Y5. Submit the appropriate fees and complete the "Underground <br />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. <br />Procedures should explain purging and/or inerting method. <br />IJ�B. 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 />13d 9. Compplete the San Joaquin Local Health District's (SJLHD) <br />"Underground 'Tank Disposition Tracking Record". The holder <br />of the permit shall, Ix 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. dvance inspection notice of at least 48 hours is re uired by <br />Fie San Jos uin i ocaL- ea i is ric �r�npria e a van <br />intion notification ot Jurisdictional isdictional fire district is <br />contractor's respons--iGTlty. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3410 <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 />Laboratory <br />466-3460 <br />Public Heal!h Nursing <br />468-3860 <br />WIC <br />468.3280 <br />