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- +EOARU`OF TRUSTEES SA`'JOAQUIN LOCAL HEALTH DiSTrtiCT� f ' � SERVING <br /> AI Crow,Pre,. San Joaquin County <br /> Ead Pimentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson. City of Lodi <br /> John D.Mast.M.D. JOG[ 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 /> Haney Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUNb G 'PAFin—gMtZrgC-RKM=S MATERIALS <br /> 1• GENERAL INSTRUCTIONS: <br /> \Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, <br /> ipinq, streets and adjacent properties (north toward the <br /> op off the page) location of nearby septic tanks, <br /> eachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewep) . <br /> Complete form "APPLICATION FOR PE%I R UNJERGRO D TANK <br /> CLOSURE". '�NIC.&MplCAe PI A U <br /> Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> Tank Program Flee Worksheet". <br /> V0600. Procedures should explain decontamination techniques if <br /> apslicable, 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 /> rPrwI"& s *hoiCLAxp_1r� pugging and/or ill, ing method. <br /> oe.00 ff►► bbppee44MM��D aii'l L�fii��.(I(ii�a YO dbt kSe�frl , <br /> Descri ill detail h w soil an /or water samples beneath the <br /> t nk's invert will be obtained. Refer to Sampling Protocol <br /> or Routine Tank Removals" for sampling criteria. <br /> Compplete the San Joaquin Local Health District's (SJLHD) <br /> "Urxlerground 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 /> ❑�11 Advance inspection notice of at least 48 hours is re uired by <br /> the anoa uin oca ea i t;; roc . Alate a vane <br /> ins .c ion no i ica -ion ci auris is lona ire is ric is <br /> con rac or resuon^i > its <br /> EH 23 040 <br /> REVISED 12/88 <br /> rJ R�sec�v) s/-1 /vR ( j'tjC i'c'e- ��Ji4 ),7-;?'l7P - Pf0uiv-Y,441 <br /> C� WM F(YRN.. FOR X)FsCwJNri4M 115P001. <br /> r) /(2E 174Si }"�E2.K�r af'f�� <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 468-3460 468-3280 <br /> ._ar✓. /,�/�... AIDS Information 468-3920 <br />