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L+Vg1HV Vr ;Itu J;tL.:r � Jl/N1+IV f1� LV LrNL I ILNL.111 �J1.. ;llV 1 <br /> AI Grow,Pres. - JtHVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. StocktonCalifornia 95205 City of Manteca <br /> Jami; ,F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews -'. City of Tracy <br /> Thomas Schubert,D.V.M City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> UNDERGIZOUNAPPLICATION FOR PERMIT TO CLOSE <br /> U--TMAMjW;�-b- MS MATER I ALS <br /> I • GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> R2. Include a detailed site map showing tank location and t per <br /> ppiping, streets and adjacent properties (north toward the <br /> top of the page) location of nearby septic tanks <br /> leachfields, buiidings and underground public utility lines <br /> (including water, sani�ary sewer and storm sewer. ) . <br /> 3. Compplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLO URE". <br />•'. 4. Complete the "Authorization to Release Analytical Data" form. <br /> 5• Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 6. Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> aril/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 /> EJ 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 /> 9. Complete the San Joaquin Local Health District's (SJLIiD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of thepermit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> Er10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11. Advance ins action notice of at least 98 hours is re uired by <br /> e San o-i uin oca ea >s ric ro ria e a vance <br /> ins c on no i ica ion o uris is lona ire is ric is <br /> Con rac orT respOn jl 1 Y <br /> FH 23 090 <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 <br /> 468-3280 <br /> AIDS Information 468-3820 <br />