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r <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SER 11 <br /> Al Crow,Pres. " rijr <br /> Joaquin County <br /> Earl Pimentel.Vice Pres- 16U1 i=a5t Hazelton AVt?nUe �.i� � � 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 .J t ^ 1989 City of Ripon <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw <br /> Harvey Williams,Ph.D. _, ?r?'q`AE V!Ai..HFAL! City:San Joaquin <br /> Stockton <br /> t,'.cs=n� in County <br /> APPLICATION FOR PERMIT TO CLOSE "' AC- : <br /> UNDERGROUNIS—MVVS MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> �� ❑ 1. Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> ! Viping, streets and adjacent properties (north toward the <br /> op 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 /> - tb 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> L�-f' 4. Complete the "Authorization to Release Analytical Data'" form. <br /> V�.a 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 0 6. Procedures should expplain 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 /> E 9. Complete the San Joaquin Local Health District's (SJLHD) <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 /> ET"10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> .1. Advance inspection notice of at least 48 hours is recruired b <br /> e San JoaQuin Local HealEh Distric ro ria e aclyance <br /> inspgction no i ica ion ot jurisdictionalire district is <br /> con rac ors responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration C!inical Services Environmental HeFIth Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-39(30 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />