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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Plmentel,vice Pres, 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyo%Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JODI 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 /> frtlnFurstnlrt��PLICATION FOR PERMIT TO CLOSE S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> d ;l. Submit all information in triplicate. USE CARBONS. <br /> 1� 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,page), <br /> dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> Cj-'3. Commplleette form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> q. Complete the "Authorization to Release Analytical Data" form. <br /> t�/'5. Submit the appropriate fees and complete the "Underground <br /> ,/ Tank Program Fee Worksheet". <br /> tt,r 6. 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 /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> 7. Procedures should explain purging and/or inerting method. <br /> Q/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 /> C 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of the permit shall. be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> 1� 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> I 11. an -ns ction notice of at least 48 hours is required by <br /> L e an oa uin oca earf� s r c ro rate advance <br /> ins cion no > >ca ion o Tums is zona ire district is <br /> contractor 's responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460.3820 408-3460 468.3280 <br /> AIDS Information 468-3620 <br />