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Al Crow, Pres. San Joaquin County <br />Earl Pimentel, Vice Pres. 1601 East Hazelton Avenue City of Manteca <br />Tommy Joyce, Sec'y. 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 City of Ripon <br />Thomas Schubert, D.V.M. San Joaquin County <br />Daphne Shaw City of Stockton <br />Harvey Williams, Ph.D. San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUN S MATERIALS <br />I (NERAL INSTRUCTIONS: <br />1., Submit all information in triplicate. USE CARBONS. <br />0--'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 />❑ 3. Completeform"APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />�� Sle•EPA � <br />VL- 4.Complete the "Authorization to Release Analytical Data" form. <br />Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />0--6-. Procedures should explain decontamination techniques if <br />materials) aterials) 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. rocedures 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 />9. Complete the San Joaquin Local Health District's (SJLHD) <br />"Underground Tank Disposition Tracking Record". The holder <br />ofthe permit shall. be res onsible for ensuring that this form <br />is completed and returned fhe SJLHD. <br />❑ 10. The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Pian. <br />❑ 1.1. <br />EH 23 040 <br />REVISED 12/88 <br />Administration Clinical Services Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />sJ PN s <br />V <br />BOARD OF TRUSTEES SAN JOAQUIN <br />LOCAL HEALTH DISTRICT <br />SERVING <br />Al Crow, Pres. San Joaquin County <br />Earl Pimentel, Vice Pres. 1601 East Hazelton Avenue City of Manteca <br />Tommy Joyce, Sec'y. 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 City of Ripon <br />Thomas Schubert, D.V.M. San Joaquin County <br />Daphne Shaw City of Stockton <br />Harvey Williams, Ph.D. San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUN S MATERIALS <br />I (NERAL INSTRUCTIONS: <br />1., Submit all information in triplicate. USE CARBONS. <br />0--'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 />❑ 3. Completeform"APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />�� Sle•EPA � <br />VL- 4.Complete the "Authorization to Release Analytical Data" form. <br />Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />0--6-. Procedures should explain decontamination techniques if <br />materials) aterials) 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. rocedures 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 />9. Complete the San Joaquin Local Health District's (SJLHD) <br />"Underground Tank Disposition Tracking Record". The holder <br />ofthe permit shall. be res onsible for ensuring that this form <br />is completed and returned fhe SJLHD. <br />❑ 10. The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Pian. <br />❑ 1.1. <br />EH 23 040 <br />REVISED 12/88 <br />Administration Clinical Services Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />