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SERVI <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT San Joaquin County <br /> At crow,Pres. 1601 East Hazelton Avenue city of Manteca <br /> Earl Pimentel,Vice Pres. Ci of Escalon <br /> Tommy Joyce,Secy. Stockton, California 95205 City <br /> of Lodi <br /> James F.CulbertsonCity of Tracy <br /> John D.Most M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER city of Tracy <br /> Virginia Mathews San Joaquin County <br /> Thomas Schubert,D.V.M. City of Stockton <br /> Daphne Shaw <br /> San Joaquin County <br /> Harvey Williams,Ph.D. <br /> APPLICATION FOR PERMIT TO CLOSE S MATERIALS <br /> UNDERQt0UNT5-SCE <br /> If GENERAL INSTRUCTIONS: <br /> LW�l Submit all information in triplicate. USE CARBONS. <br /> ;, Include a detailed site map showing tank location and type, <br /> ipinq, streets and art acent properties (north toward tKe <br /> p of the paga) loca ion of nearby septic tanks <br /> eachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. �ComRlete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> L!!'5. S it the appropriate fees and complete the "Underground <br /> tank Program Fee Worksheet". <br /> 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 /> pacify the responsible party(ies) who will be disposing of <br /> wasote generated on site. <br /> 7. cedures should explain purging and/or inerting method. <br /> 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 /> ❑ 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 /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ ].1. Vance inseectlon notice of at least 48 hours is re uir-ed by <br /> Lfie� U urn—Loca�Aea iIEf—LSis 'c �ro�r a e a Vance <br /> ins c ion notification_ of jurisdictional fire district is <br /> con rac <br /> or's responsibility. <br /> oonsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468.3830 468-3420 468-3960 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />