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HOARD OF TRUSTEES SAla''JOAQUIN LOCAL HEALTH DISTr.R;T SERVING +, <br /> ' Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 city of Eseaton <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. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County I <br /> APPLICATION FOR PERMIT TO CLOSE i <br /> UNDERGROUNT-�;�TMKT- 'IMR?)1GTlA'M7MOS MATERIALS j <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ 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, ui�dings and underground public utility lines <br /> (including water, saniLry sewer and storm sewer) . <br /> ❑ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> ❑ 4. Complete the "Authorization to Release Analytical Data" form. <br /> ❑ 5. Submit the apppropriate fees and complete the "Underground = t <br /> Tank Program Fee Worksheet". <br /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation W o, = u <br /> lZ <br /> an storage of hazardous waste generated on site and m "- > <br /> specify the responsible party(ies) who will be disposing of W w <br /> waste generated on site. W Z <br /> t : <br /> —❑-7. Procedures-should explain purging and/or inerting method. Q W Z 0- t <br /> Cl 8. Describe in detail how soil and/or water samples beneath the IL °z n <br /> tank's invert will be obtained. Refer to "Sampling Protocol Z <br /> for Routine Tank Removals" for.sampling criteria. W <br /> ❑ 9. Complete the San Joaquin Local Health District's (SJLFID) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of the permit shall be re:;uonsible for ensuring that: this f.or.m <br /> is completed and returned the SJLHD. <br /> ❑ 10. The maximum review time for Closure Plans is 15 working days f' <br /> from the date of receipt of the adequately completed Plan. t <br /> ❑ 11. Advance ins ction notice of at least 48 hours is required by 18 <br /> e an oa uin oca ea i is ruppronria e advance <br /> ins cion no i ice ion o iuris i iona�fire district is <br /> contractor's responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Ef s/-r 14P C ece 91� V-711/747 _ P"FA-f7 <br /> ;i <br /> ❑ WM FUKIA, FoT+ VRC.V4trfFM �` .bL0d & <br /> �) f/PC 0457 <br /> 3 <br /> 1 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 .i <br /> t <br /> Air Pollution Community Services Laboratory WIC ' <br /> 468-3470 468-3820 468-3460 468-3280 ; <br /> i <br /> AIDS Information 468.3820._ _ - ___._ ___—__ - ___— <br />