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r , <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentei,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.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 /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND S Mr-'Y' S STORING S MATERIALS <br /> CIIdERAL INSTRUCTIONS: <br /> 0/ <br /> �, <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> [2/2. Include a detailed site map showing tank location and type, <br /> piping, streets and adJacent properties (north toward the <br /> top of the Page), location of nearby .septic tanks <br /> leachfields, buidings and underground public utility lines <br /> (includin water, sai�ary sewer and storm sewer) . <br /> [R/3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Ci' 4. Complete the "Authorization to Release Analytical Data" form. <br /> 9---'5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 8--6. Procedures should explain decontamination techniques if <br /> applicable, materiallls) 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 /> 2 7 Procedures should explain purging and/or inerting method. <br /> (t�' S. 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 (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of the permit shall be responsible -for ensuring that this form <br /> is completed and returned the SJLHD:'Z Wk. C:0- -ap"j�r � <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. Advance ins ection notice of at least 48 hours is required by <br /> L e San Joaauln Loca Re—aTEE District. ro ria e advance <br /> in�s�ec�iof on o lures is ional tire distric is <br /> contractor's responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Admiptstration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 463-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 468-3460 468-3280 <br /> AInR Inlnrmntinn AAn.in9n <br />