Laserfiche WebLink
/-'A <br /> sca" OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AJ Craw,Prem SM Joaquin ComM <br /> Earl Pimentel,Moe Pr" 1801 East Mershon Avenue GM u Manleea <br /> Tommy Jmyce,Secy Stockton,California 95205 GM f Eaulan <br /> James F.Culbe"sen City o alon <br /> John D.Mast,M.D. JOOI KHANNAJ M.D, M.P,11., DISTRICT NMTN OFFICER �,of Tracy <br /> ThomaLodi <br /> VirginiMatMwa City of Ripon <br /> Thomas Schubert D.V.M. <br /> Daphne ShawSon <br /> of Sbeklon <br /> Sen Joaquin County <br /> Harvey Williams,PhD. Sin Joaquin County <br /> D 0R APPLICATION FOR PRRMIT TO CLOSE <br /> 1 I . C'FNERAL INSTRUCTIONS: 1 <br /> ® 1. Submit all Information in triplicate. USE CARBONS. <br /> 93'2. Include a detailed site map shoving tank location and type <br /> ptptnyy, streets and adiacent properties (north toward the <br /> top 0f the page) location of nearby septic tanks <br /> leachfields, bu�idings and underground public utility lines <br /> �/ (including water, sani♦ary sewer and storm sever). <br /> (11 3. Complleette•form "APPLICATION FOR PERMIT FOR UNDERCROLUD TANK <br /> fjK4. Complete the "Authorization to Release Analytical Data" form. <br /> riY5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee, Worksheet". <br /> ❑ G. Procedures should explain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> alxl/or storage of hazardous waste generated on site, and <br /> specify the responsible party(les) who will be disposing of <br /> waste generated on site. <br /> M "7. Procedures should explain purging and/or inerting method.. <br /> Q'8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sam ling Protocol <br /> for Routine Tank Removals for sampling crater a. <br /> 551�9. Complete the San Joaquin Local Health District's (sJLHD) <br /> "Underground Tank Disposition Tracking Record". The ho der <br /> of the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> ❑ 10. The maximum review time for Closure Plans Is 15 worksng days <br /> from the date of receipt of the adequately completed Plan. <br /> Ind 11. Tdva ce s ice of t e ou a ed <br /> e a a r><a van <br /> ins .cotiricLatioo <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration ClIn"servion <br /> 460-34001401110114X118- ,� En Health Public HeaM Numing <br /> 3420 46m-91160 <br /> Alr Pollution Community Servlcee Laboratory W� <br /> 41111.9670 X1111-9620 4611.34M 466.3280 <br /> AIRF Ino 0*w a.e IV" <br />