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SAN JOAQUIN COUNTY <br /> BOARO Of TRUSTEED PUBLIC HEALTH SERVICES SERVING <br /> AfCrow,Pros, ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Earl Pimentel.Vice Pres. P 0 BOX 2009, STOCKTON, CA 95201 City of Manteca <br /> Tommy Joyce,Secy. City of Escalon <br /> Jam"F.Culbertson - City of Lodi <br /> John D.Most,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. <br /> Daphne Shaw San Joaquin County <br /> Hervey Williams,PhDCity of Stockton. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND-`1MC S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> ,12. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> to of the Pagel, location of nearby septic tanks, <br /> leachfields, uiidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. C <br /> omplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> 33len <br /> U`4. Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> K Tank Program Fee Worksheet". <br /> Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> af�d/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 metha9. <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, mak; <br /> 9. Compplete 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 /> 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the y _completed Plan. <br /> 11. Ad va c s e d o o ice of icieasi 48 ou Line u an nboncsi reawi_red <br /> b <br /> y <br /> a Health a adrence <br /> cQceractornnreion of Jurisdictional tire district-is <br /> i v <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Heal!h Nursing <br /> 468.3400 468-3030 468.3420 468-3060 <br /> Air Pollution Community Services Laboratory wl� <br /> 468.3410 460.3820 468-3460 468.3280 <br /> AIDS Information 468.3020 <br />