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�I now OF rnUSTEEs SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> N Crew,Pros. San Joaquin County <br /> Earl Plme tK Vlae Pry 1601 East Hazelton Avenue city of Manteca <br /> TTOMMYJ may. Stockton, California 95205 City of Escalon <br /> MMF. City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.M., 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 /> Hervey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDWGROUNU-MMM TANKS sIMTRUMMMMS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> Q 1. Submit all information in triplicate. USE CARBONS. <br /> 0 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, bui dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> { 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Q 4. Complete the "Authorization to Release Analytical Data" form. <br /> GI 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 1 6. 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 /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> 0 7. Procedures should explain purging and/or inerting method. <br /> 1) 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 /> 0 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 aril returned the SJLHD. <br /> 110. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> a'll. Advance nsl3ection notice of at least 48 hours is re uired b <br /> EFe an Joe ui )-Aea i s r c ro ria e a vance <br /> insccion no mica ion o ur>s is lona ire id s rict is <br /> con roor 's responsinility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services laboratory WIC <br /> 468-3470 468.3820 408-3460 468-3280 <br /> AIDS Information 468-3820 <br />