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moo <br /> / BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT 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 Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.O., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> City of ninon <br /> Thomas Schuler,D.V.M. <br /> Daphne Shaw San Joaquin Count' <br /> City of Stockton <br /> Harvey Williams,Ph.D, San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE UNDE2GROUNE�b`Tb1FA� S MATERIALS . . <br /> I. GENERAL INSTRUCTIONS: <br /> U' 1. Submit all information in triplicate. USE CARBONS. <br /> D 2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> rop of the page) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> [�� 3. CommplleeEte form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> 1714. Complete the "Authorization to Release Analytical Data" form. <br /> l� 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 6. Procedures should explain decontamination techniques if <br /> applicable, materials) 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 /> E73. 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 /> Cl 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 /> 0'10. 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. Advance ins action notice of at least 48 hours is required b <br /> -h an oa uLn ocaI—AeaIth District. ADoroDriate advance <br /> in ec ion no i Ica ion o ' jurisdictional tire district is <br /> con rac or 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 468.3460 468-3280 <br /> AIDS Information 468-3820 . <br />