Laserfiche WebLink
-BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> ow,Pres. San Joaquin County <br /> Al Cr <br /> Earl ow,Pres vice Pros. 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. 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. San Joaquin County <br /> City of Stockton <br /> Daphne Shaw <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUN �S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> �a ul <br /> lYt Submit all information in triplicate. USE CARBONS. ' <br /> r;--f <br /> 2. Include a detailed site map showing tank location and type, <br /> ipinq, streets and adjacent properties (north toward the <br /> op of the page) location of nearby septic tanksLI;cnLTH <br /> leachfields, bU dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> mpplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> 4omplete. <br /> LLL 4 Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> ank Program Fee Worksheet". <br /> 6. Procedures should explain decontamination techniques if <br /> ap licable, material(s) utilized for rinsate, transportation <br /> an or storage of hazardous waste generated on site, and <br /> cify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> �� �77. Procedures should explain purging and/or inerting method. <br /> [g 8. Describe in detail how soil and/or water samples beneath the <br /> nk's invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> f the permit shall be responsible for ensuring that this form <br /> Z10. <br /> completed and returned the SJLHD. <br /> maximum review time for Closure Plans is 15 working days <br /> rom the date of receipt of the adequately completed Plan. <br /> 11. Advance ins ction notice of at least 48 hours is re uired by <br /> t e an oa HE oca ea District. ro ria e a vane <br /> ins cion no i ica ion ouris is lona ire is ric is <br /> con rac or—ls responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <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 4FR3S9n <br />