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SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> III OF TRUSTEES San Joaquin County <br /> At Crow,Plea. 1601 East Hazelton Avenue City of Mameca <br /> Earl Pimentel,Vice Pres. Stockton, California 95205 City of Escalon <br /> Tommy Joyce.Secy. City of Lodi <br /> James F.CulbertsonCity of Trac <br /> John D.Mast M.D. JOGI KHANNA. M.D., M.P.N., DISTRICT HEALTH OFFICER City of Ripon <br /> Virginia Mathews San Joaquin County <br /> Thomas Schubert.D V.M. City of Stockton <br /> Daphne Shaw San Joaquin County <br /> Hervey Williams,Ph.D. <br /> APPLICATION EYIFt PERMIT TO CLOSE <br /> D r S MATEBIH�ti£ <br /> UNROUII <br /> I . GENERAL INSTRUCTIONS: <br /> Submit all information In triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and tyype, <br /> piping, streets and adjacent properties (north toward the <br /> tOp of the pa e) location of nearby septic tanks <br /> leachflelds, buildings and underground public utility lines <br /> /, Com <br /> (including water, sanitary sewer and storm sewer) . <br /> plete form "APPLICATION EOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Data" form. <br /> y Submit the appropriate fees and complete the "Underground <br /> /Tank Program Fee Worksheet". <br /> d1 Procedures should ex lain decontamination techniques if <br /> ap licable, materialls) utilized for Ansate, transportation <br /> a�/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 /> 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 /> 7• Complete the San Joaquin Local Health District's (SJLiID) <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. working 110, frommom themum datereview <br /> receiptfor <br /> of theClosure <br /> adequIs <br /> adequately mpletedlPlan. <br /> lIY, va c ns ction notice of at least 98 hours is 1 ed <br /> in oca ea cl r c nnLe r a e vanes <br /> fns ec Ion no ca ion o 'urts c lona Tredistricts <br /> con rac or s resn0ns�161Iiy. <br /> EH 23 090 <br /> REVISED 12/88 <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 /> 468-3170 <br /> 466-3820 468-3460 468-3260 <br /> AIDS Information 468-3820 <br />