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v <br /> J <br /> BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimento(,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Selly. 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 f�NDE1RGR0UN S MATEIRIALSRe��tv1© <br /> I. GENERAL INSTRUCTIONS: Q® ,�� '(��� <br /> lam. Submit all information in triplicate. USE CARBONS. A ENtA�HEAtTFI <br /> 0-�-2. Include a detailed site map showing tank location an�M RVICES <br /> piping, streets and adjacent properties (north towar e)ERM(T�SE <br /> M of the Pa e) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 2�-3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> C9'4. Complete the "Authorization to Release Analytical Data" form. <br /> 1r5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> (T'6. Procedures should explain decontamination techniques if <br /> applicable, material(s) 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 /> '0-17. Procedures should explain purging anus/or inerting method. <br /> Lfi8. 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 /> COY 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 /> a 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> LJ ii. nu Van ce ins Ction noti.CE Cf at leapt 48 h8llY5 1S 1"2 IrEd t'i' <br /> e ah Oa ulh Localea it r1C r0 Yia e a vance <br /> ins C ion notification of Jurisdictionalire district is " <br /> COn raC Or s responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> d s0 <br /> Aso'd. <br /> cry a ° <br /> Date* <br /> 3��q <br /> 00: <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 /> 468-3470 468-3820 468-34e0 468-3280 <br /> AIDS Information 468-3820 <br />