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{IUARDOF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> San Joaquin County <br /> At Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,vice Pres. Ci of Escalon <br /> Tommy Jnyce,Secy. Stockton, California 95205 N <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 ///�� ' n City of Ripon <br /> Thomas Schubert,D.V.M. ` / / �/1 /, � San Joaquin County <br /> Daphne Shaw J (fir{'// ��/ City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATTON FOR PERMIT TO Ct.OSE <br /> UNDERGROUNb 5r1�Tf�C`Lr 1`�1{CS i1c5{FINL`-FTA'LAMMS MATERIALS <br /> I GENERAL INSTRUCTIONS: <br /> LSubmit all information in triplicate. USE CARBONS. <br /> p�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 water, sanitary sewer. and storm sewer. ) . <br /> L7 3. G�mpptete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> Wank Program Fee Worksheet". <br /> t a_G. Procedures should explain decontamination techniques if <br /> appplicable, material(s) utilized for rinsate, transportation <br /> atx9/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 /> CY8. 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 /> a-9. Compplete the San Joaquin Local I(ealth District-'s (SJLIID) <br /> "Ufx9erground Tank Disposition Tracking Record". The holder <br /> ofthe ppeermit shall be responsible for ensuring that this form <br /> is completed and 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 ins ection notice of at least 48 hours is required bth y <br /> San as uinZocT ea Is rIc ro ri'Te advance <br /> ins c ion no I -Ica -Ion o _-urls is Iona 'Ire d t_ s rlcf�is — <br /> con -rac or s resL!Ulu l I I v <br /> EH 23 040 <br /> REVISED 12/88 <br /> i <br /> Administration Clinical Services <br /> 468-3400 Environmental Heallh <br /> 468.3830 p <br /> yr varu6on466-3420 <br /> 4eea.r,o Community services /Mrl <br /> 468-3820L, Ny� yq !I <br /> 1� boralory ' rlyq/I <br /> 466.3460 /61/I/. <br /> ---VicA-President <br /> N!! <br /> 1I!!!!!!U!!11,1111L0C - _ _ . -DATE 3/31/89 <br /> nan_v�nn DE <br /> is CODf AMDUMT � !! sl!!r!a!r!!!n!u!!!!!!!!!!!!!!!!s!!!!!!!!!!!!! <br /> a—!!!!!!!!!!!! a RCVD � <br /> RCVp ' DAT R <br /> vs p MIT ! <br />