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WAR'-, OF TRUSTEES SA14 )AQUIN LOCAL HEALTH DISTR SERVING <br />Al Crow, Pres. Nwo, *0 04 San Joaquin County <br />Earl Pimental, Vice Pres. 1601 East Hazelton Avenue City of Manteca <br />Tommy Joyro, Secy. Stockton, California 95205 City of Escalon <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 <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROl1Nl�3�[�€F�rF TAIIhrS S'ibltiN(TAAA72S MATERIALS <br />I. GENERAL INSTRUCTIONS: PAYMENT <br />OR -1. Submit all information in triplicate. USE CARBONS. RECEIVED <br />❑ ?y2 Include a detailed site map showing tank location and t A OV 13 M9 <br />piping, streets and adjacent properties (north toward t�ANJOA UIN COUNTY <br />ttop of the Page) i location of nearby septic tanksQ <br />leachfields, bui dings and underground public utili iH SERVICES <br />(including water, sanitary sewer and storm sewer). A4NGA <br />03. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />04. Complete the "Authorization to Release Analytical Data" form. <br />FGY5. Submit the apppropriate fees and complete the "Underground <br />'Tank Program Fee Worksheet" <br />06. Procedures should explain decontamination techniques if <br />applicable, mater.ial(s) utilized for. r'insate, transportation <br />an�/or storage of hazardous waste generated on site, and <br />specify the responsible party(i.es) who will be disposing of <br />waste generated on site. <br />%. Procedures should explain purging and/or inerting method. <br />E:-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 />❑ 9Q 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: Lhis form <br />is completed and returned the SJLHD. <br />1&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. <br />EH 23 040 <br />REVISED 12/88 <br />EDM4110,M) S/0 NR l CA?C I'd I t '//6 00 /7tfl -- l�f'G��. 15 COO Is ��r�� <br />[I WM r0f¢N• Fon ��f. NTAM Dfsi�?� <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Enytronmental Hoalth <br />468-3420 <br />�Et(• 3/U/P6 AIDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />