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0OAR9 OF TRUSTEES SA._._ JOAQUIN LOCAL HEALTH DIST,.oCT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Ead Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 city of Fscalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI �!p DISTRIGT KED„_-,.LT ^FFICER City of Tracy <br /> Virginia Mathews �1 19�R. Si IM(! ,' City of Ripon <br /> Thomas Schubert,D.V.M. L. . .rp a Dr., Ste. - R San Joaquin County <br /> Daphne Shaw &ulatton, CA 98208 City of Stockton <br /> Harvey Williams,Ph.D. - 94"IM San Joaquin County c <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ 1. Submit all information in triplicate. USE CARBONS. I4 <br /> V'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, buildings and underground public utility lines <br /> (including water, sanitary Sewer and storm sewer) . <br /> LrJ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> S' $ Complete the "Authorization to Release Analytical Data" form. <br /> �s Pats„�+�f 5. Submit the apropriate fees and complete the "Underground <br /> � Tank Program fee Worksheet". s` <br /> L7 6. Procedures should explain decontamination techniques if L <br /> mlivable, material(s) utilized for rinsate, transportation I <br /> /or storage of hazardous waste generated on site, and A' <br /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> A,. <br /> I: <br /> /7. Procedures should explain purging and/or inerting method. <br /> Ly 8. Describe in detail how soil and/or water samples beneath the k <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> -- for Routine Tank Removals" for sampling criteria. <br /> �,G Fi <br /> lK 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 /> R�CM0✓ 63!FR2sDeE <br /> Advance ins cof at east48 hours is re uired b <br /> y aoa u>nova ca >s rE ro ria e advance on <br /> notification o nuri;> is lona .ire district -is �x <br /> contractor 's responsibility. s <br /> EH 23 040 <br /> REVISED 12/88 <br /> MAR 2 199 r <br /> L , ,.rH <br /> i <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 /> AIDS Information 68-3820 <br /> 8616 3/17 75ti4 ;; <br />