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BOARD OF TRUSTEES SAN~JOAQUIN LOCAL HEALTH DISI FST 3� SERVING <br /> Af Cow,Pres San Joaquin County <br /> Earl Aimentel,vice Pres. 1601 East Hazelton Avenue - /�� '� /'►a�� city o1 Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 C_ City o1 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. <br /> Daphne Shaw San Joaquin County Harvey Williams,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> —/1. Submit all information in triplicate. USE CARBONS. <br /> Q 2. Include a detailed site map showing tank location and type, <br /> iping, streets and adjacent properties (north toward the <br /> opo the page} location of nearby septic tanks, <br /> leachfields, 5uifdings and underground public utility lines <br /> D'/ (including water, sanitary sewer and storm sewer) . <br /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> �2 4. 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, 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 /> 917. Procedures should explain purging and/or inerting method. ; <br /> L1✓ B. 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 /> 13/9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record" The holder <br /> of the permit shall be res onsible for ensuring that this form <br /> is completed and returned �he 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 /> ❑ 11. Advance insction notice of at least 98 hours is re iced b <br /> e San oa uin oca.1 Health District. ro ria e advance ! <br /> inspgction notification o oris is lona ire district as <br /> con rac or_sresponsibility. i <br /> EH 23 040 <br /> REVISED 12/88 <br /> lyJ,/ <br /> B;r _,r s ATG )V 1Z <br /> iYrr M FoPm w 1 1 i4 s o-�­rOfJTPM 1 n{ �0 <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 /> AIDS Information 468-3820 <br />