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BOARD pr TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pros. <br /> Earl SERVING <br /> Tommy <br /> Vice pros. 1601 East Hazelton Avenue San Joaquin county <br /> James <br /> Secy, Stockton, Californiaity of Manteca <br /> mess FF..Culbertson <br /> ertson a 95205 City of Escalon <br /> , M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> John D.Meat M.D. JOGI KXANNA <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey William&,Ph.D. City of Stockton <br /> San Joaquin County <br /> UNDERGRQ0APPL TI♦ON FOR PERMIT TO CLOSE <br /> S MATERIALS <br /> I/ GENERAL INSTRUCKONS: <br /> ue/1. Submit all information in triplicate. USE CARBONS. <br /> ❑ 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, ul dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> LV 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 9 Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> UYZTank Program Fee Worksheet". <br /> 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 /> 0 7. Procedures should explain purging and/or inerting method. <br /> Describe in detail how soil and/or water samplesbeneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> P 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of thepermit shall. be responsible for ensuring that this form <br /> is completed arld returned the SJLHD. <br /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11. Advance 'ns ction notice of at least 48 hours is re uired by <br /> L e an oa >n oca t is r>c ro ria e a vane <br /> in Dec ion no mica ion o iuris is ions ire id's ric is <br /> contrac o�s responsinIlry. <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 468-3460 468-3280 <br /> AIDS Information 468-3020 <br />