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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimental,Vice Free. 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. JOGI 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 /> Harvey Williams,Ph.D. - San Joaquin County <br /> APPLICATION rOR PERMIT TO CLOSE UNDERCROUt.)� S MATERIALS <br /> _ I. GENERAL INSTRUCTIONS: <br /> lid/1 Submit all information in triplicate. USE CARBONS. <br /> l 2. Include a detailed site map showing tank location and type, <br /> pipiny, streets and adjacent properties (north toward the <br /> top of thegge)) location of nearby septic tanks, <br /> leachfields, bui�dln,ls and underground public utility lines <br /> (including water, sanifary sewer and storm sewer) . <br /> Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". 44 <br /> LY 9. Complete the uthorization to Release Analytical Data" form. <br /> • Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet''. <br /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, materias) utilized for rinsate, transportation <br /> and l <br /> /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 /> � <br /> 7. Procedures 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. <br /> 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 Lhe 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. Adva c s ction ot, of at least 48 hours is required by <br /> EMU a utn oca Rea . i is rtct.—A ro rlTadvanct <br /> ins <br /> on not ica .Ion O Turas is >onZ �fireLdistric�is <br /> con rac or —9r, r iy <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administra8on Clinical Services Environmental Haalth Public Haal!h Nursing <br /> 466-3400 468-JO30 468.9420 468-3960 <br /> Air Pollution Community Services Laboratory WIC <br /> "170 gsa.•A9^(a 468-;,460 468-3280 <br />