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BOARD 6F 'i RUSTEES <br />AI Crow, Pres. <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce, Secy. <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />0 46 Copy <br />SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />San Joaquin County <br />1601 East Hazelton Avenue <br />City of Manteca <br />Stockton, California 95205 City of Escalon <br />City of Lodi <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND S MATERIALS <br />I. GENERAL INSTRUCTIONS: <br />. Submit all information in triplicate. USE CARBONS. <br />E2/2. 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, buildings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />IBJ- 3. Complete form "APPLICATION I -OR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />rtn-4. Complete the "Authorization to Release Analytical Data" form. <br />W-5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />WW 6. Procedures should explain decontamination techniques if <br />applicable, materials) 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 />7. Procedures should explain purging and/or inerting method. <br />8. 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 />EiP 9. Comglete 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. <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 />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />