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i <br /> 61?t <br /> 0ARO OF TAUSTM SAID JOAQUIN LOCAL HEALTH DISTRICT eERVING <br /> I Al Crow,Pref. San Joaquin County <br /> Earl Pltnsrltel,Vice Prez, 1$61 East Hazelton Avenue City of Mannas <br /> Tommy Joyce,sec'r• Stockton,California 85205 City of Eacaton <br /> James F.Culbertson City of Lodi <br /> John D.Maiat,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of rllpon <br /> Thomas Soluboirt.D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AAPLICATI PF2M T CLOSE <br /> LEDIERCRQWD <br /> C;WERAL. INSTRt=I ONS: <br /> �. Submit all information in triplicate. USE CARBONS. <br /> ®/2. Include a detailed site map showing tank location and type, <br /> ?iping, streets and adgacent properties (north toward M <br /> I op o the page lova ion of nearby..septic tanks <br /> leachfields, bu�idings and underground public utility lines <br /> (including water, sanitary serer and storm sewer). <br /> a !�' 3. Complete form '"APPLICATION FOR PERMIT 110It UND2t20UND TANK <br /> / CLOSURE". <br /> CIV • Complete the "Authorization to Release Analytical Data" form. <br /> t C 5. Submit the ap ropriafe fees and complete the "Underground <br /> r i/ Tank Program Pee Worksheet". <br /> C� 6. Procedures should elain decontamination techniques if I <br /> applicable, materlal(xxpps) utilized for rinsate, transportation <br /> and/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 /> t1l'7. Procedures should explain purging anti/or inerting method. <br /> �8. Describe in detail how soil and/or water samples beneath the <br /> rank's invert will be obtained. Refer to "Sampling Protocol <br /> � Eor Routine Tank Removals" for sampling criteria. <br /> t/ 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 a!xl returned L'he SJLHD. <br /> . The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> 11• 't o fce o at tgmrg <br /> f=40 anY <br /> ' <br /> g u A -Dia <br /> e <br /> t 2 �� on of, jurIgg <br /> r EH 23 040 <br /> f MISED l2 ;v <br /> t. <br /> I <br /> Administration Conical Services Environmental Health Public Health Nursing <br /> 488.3400 488-3630 469.3420 488-3360 <br /> Air Pollution Community SarviCe! Laboratory yylc <br /> 408.3470 490.3820 400-3480 498-3280 <br /> i AIDS Information 468.3820 <br />