Laserfiche WebLink
.a <br /> BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue <br /> 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 /> Vlrglnla Mathews City of Ripon <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Wlliisms,Ph.D, San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> S MATERI S <br /> I. GENERAL INSTRUCTIONS: <br /> � <br /> L�,1/I. Submit all information in triplicate. USE CARBONS. <br /> Cg 2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> op of the pa e� location of nearby septic tanks, <br /> leaehfields, gbui,dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 2/3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 11 l <br /> /Q4. 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 /> and/or storage of hazardous wast=e generated on site, and <br /> specify the Lesponsible party(ies) who will be disposing of <br /> waste generated on site. <br /> Procedures should explain purging ant]/or inerting method. <br /> �117/ <br /> 8. Describe in detail how <br /> 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 thepermit shall be responsible -for ensuring that this form <br /> is completed and returned he SJLHD. <br /> L./30The maximum review time for Closure Plans is 15 workingdays <br /> C,/ from the date of receipt of the adequately completed Pan . <br /> L '11. Advance ingggction notice of at least 48 hours-.,is s rr u red b <br /> L e - an oa u n oca A-a s ric . ro ria e a vance <br /> >ns ec o <br /> in no x ica ion of urns �c xona tire district �s <br /> c n a n <br /> �s si > <br /> EH 23 040 <br /> REVISED 12/88 <br /> i <br /> Administration Clinical 5ervlce3 Environmental Health Public Heafth Nursing <br /> 468-3400 468-3330 468-3420 468-3360 <br /> Air Pollution Community Services Laboratory Wic <br /> 468.3470 468.3820 408-3460 4SP-178n <br />