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Prt OF-TRIJS�CS <br />Erl Pimental, Vice Pres. <br />ommy Joyce, Secy. <br />James F. Cz,Rmrtson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />SAVAOUIN LOCAL HEALTH <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />DIS f yT F(7w &f <br />/ SERVING <br />G�„�,,,,�y vJoaquin County <br />w r •' /'wCity of Manteca <br />City of Escalon <br />City of Lodi <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERIX�OUNIFG�1'ANk`S'145RT11G�fA'1Ai21�DS MATERIALS <br />GENERAL INSTRUCTIONS: <br />1. Submit all information in triplicate. USE CARBONS. <br />1/2. Include a detailed site map showing tank location and type, <br />piping, streets and adjacent properties (north toward the <br />top of the page) location of nearby septic tanks, <br />leachfields, page) location <br />and underground public utility lines <br />(including water, sanHary sewer and storm sewer). <br />IV3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />�4 <br />CLOSURE". <br />. Complete the "Authorization to Release Analytical Data" form. <br />CB/5. Submit the apppropriate fees and complete the "Underground <br />'Tank Program eee Worksheet". <br />Procedures should explain decontamination techniques if <br />applicable, Inaterial(s) utilized for rinsate, transportation <br />and/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 />L7 <br />8. <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 restonsible for ensuring that: this form <br />is completed and returned he 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 />❑ 11. <br />EH 23 040 <br />REVISED 12/88 <br />Of�(sec,�) <br />0 Arm FORM FoR DecU&T,41A if.` .DtS?as7a <br />!I rRE v 4sT Pea^,r j fe'i� - /// S'J/-HD Ill pH ;4- <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services Environmental Health <br />468-3830 468-3420 <br />Community Services laboratory <br />466-3820 468-3460 <br />REV AIDS Information 460-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />