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WARD OF TRUSTEES SAs d0AQUIN LOCAL HEALTH DIST wCT 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 <br /> James F.Culbertson, City of F_seaton } <br /> 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 I <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUNT-9�l%RTCg--g445t?rffG�fA-DUMTS MATERIALS <br /> I*4 GENERAL INSTRUCTIONS: <br /> 2/11.�. Submit all information in triplicate. USE CARBONS. <br /> 9--'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, buiidings and underground public utility lines <br /> (including y � ,wate�,r,�sani�ry sewer and storm sewer) . X3 4Ze" Fu t <br /> 3. Co lydp ete form'AIjPLICA'ItYON FOR PERMIT FOR,CUNDERGROUND TANK <br /> CLOSURE''. S r� al-10 O,'C v a jce eL <br /> Complete the ' Authorization to Release Analytical Data" forin_Ad <br /> 5. Submit the apppropriate fees and complete the "Underground <br /> �\3 Tank Program L'ee Worksheet". <br /> IlY6. Procedures should explain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> an storage of hazardous waste generated on site, and <br /> 41 specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> 7. rocedures sho�ullduexp�la}n purging and/o inerting method. 1�-; <br /> Describe indetail haw 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 /> a, 9. Compplete the San Joaquin Local Health District's (SJLHD) <br /> "U !rground Tank Disposition Tracking Record". The holder <br /> of the permit shall be res onsible for ensuring that: this form <br /> is completed and returned the SJLIiD. <br /> ❑ 10. The maximum review time for Closure Plans is 15 workirt days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11 Advance inspection notice of at least 48 hours is re wired by <br /> e an oa win oca ga 1District. ro ria e a vane <br /> ins .c ion no i ica ion o auris is Lona ire district is <br /> con rac ors responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> L7 Y�F�{59cTZJ) sir 14R a i'c'y- ��iN )3��/Id'/ - Ps cp.0 f� Uv�fo� (�✓1/ <br /> r <br /> CI WM FaRM Fs; D8c44tr/+M ,DfsPasifc <br /> rl "flfzg 1-74ST Pen.k,r DFa-.e.,. C``i S-U/-H.D .t'rf+,. L i <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 /> _ary_ ..�1.•,/ni__.. _ AIDS Information 466-3e2h <br />