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�. BOARD OF TRUSTEES <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 />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUNU-o" (, TOR"' 1: 1M[ rffC-M-Mi OS MATERIALS <br />I. <br />GENERAL INSTRUCTIONS: <br />SA#OAQUlN LOCAL HEALTH DlSTIOT <br />SERVING <br />j <br />1601 East Hazelton Avenue <br />San Joaquin County <br />City of Manteca <br />z <br />Stockton, California 95205 <br />City of Escalon <br />City of Lodi <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />City of Ripon, <br />3. <br />San Joaquin County <br />City of Stockton <br />. <br />San Joaquin County <br />a: <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUNU-o" (, TOR"' 1: 1M[ rffC-M-Mi OS MATERIALS <br />I. <br />GENERAL INSTRUCTIONS: <br />1. <br />Submit all information in L-riplicate. USE CARBONS. <br />` <br />--�/2 <br />Include a detailed site map showing tank location and tyype, <br />piping, streets and adjacent properties (north toward the <br />top of the page) location of nearby septic tanks <br />leachfields, page) <br />and underground public utility lines <br />( including <br />water, sanHary SE-wer and storm sewer) . <br />3. <br />Complete form "APPJ�ICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE'S. Nem <br />�,q <br />. <br />Complete the "Authorization to Release Analytical Data" form. <br />lout' (U --U <br />Program <br />;�':-v� <br />Submit the apppropriate fees .and complete the "Underground <br />tc;: <br />La l �scl <br />Tank Fee Worksheet". <br />Procedures should explain decontamination techniques if <br />applicable, material(s) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />v <br />specify the responsible party(i.es) who will be disposing of <br />waste generated on site. <br />7. <br />Procedures should explain purging and/or inerting method. <br />DI <br />Describe in detail how soil and/or water samples beneath the <br />"Sampling <br />tank's invert will be obtained. Refer to Protocols <br />for Routine Tank Removals" f.or.sampling criteria. <br />Complete the San Joaquin Local Health District's (SJLFID) <br />"Underground 'Tank Disposition Tracking Record". The holder <br />of the permit shall be re.,;pOnsible for ensuring that: this form <br />is coinp eted and returned Lhe SJLHD. <br />The maximum review time for Closure Plans is 15 workirtg days <br />from the date of receipt of the adequately completed Plan. <br />R <br />contractor respon_:;PHI l <br />EH 23 040 r <br />REVISED 12/88 <br />s{7£ NR l 4'� C <br />tre tion 0 v 1� r <br />�� WM Xa'►LN• FJi1 �iC�Jf/T.4M !� .Dt.5V�r25%fL <br />Ir <br />Administration Clinical Services Environmental Health Public Health Nursing <br />468-3400 468-3830 468-3420 468-3860 <br />Air Pollution Community Services Laboratory WIC ' <br />468-3470 468-3820 468-3460 468-3280 <br />