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BOARD OF TRUSTEES SA JOAQUIN LOCAL HEALTH DISACT 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 />UNDERGROUNDST=ESTORING-HAZARDOUS MATERIALS <br />I. GENERAL INSTRUCTIONS: <br />❑ Submit all information in triplicate. USE CARBONS. <br />Include a"detailed site map showing tank location and type <br />iping, streets and adjacent properties (north toward the <br />r <br />Vop of the page) location of nearby.septic tanks <br />leachfields, buildings and underground public utility lin s <br />irris1 ding wat r, I nHa�r'y�e er an st �m sewer). Vj <br />3. Complete form "APPLICATION FOR PERMIT FOR DERGROUND ANK 1.9 ® sS f <br />CLOSURE". <br />4. Complete the "Authorization to Release Analytical Data" form. <br />5tank <br />t the appropriate fees and complete the "Underground <br />Program Fee Worksheet". <br />6. dures should exlain decontamination techniques if <br />applicable, materialgs) 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 />rite generated on site. <br />7. rocedures should explain purging and/or inerting method. <br />8. DncTib.ein detail how soil and/or water samples beneath the <br />nk's invert will be obtained. Refer to "Sampling Protocol <br />Zfor Routine Tank Removals" for sampling criteria. <br />9Complete the San Joaquin Local Health District's (SJLHD) <br />"Underground Tank Disposition Tracking Record". The holder <br />f the permit shall. be responsible for ensuring that this form <br />is completed and returned the SJLHD:' <br />_710. e 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 />%IDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />