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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escaion <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 FOR PERMIT TO CLOSE <br /> UNDERGROUND S MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> ❑ 1 Submit all information in triplicate. USE CARBONS. <br /> V'G' 2. Include a detailed site map showing tank location and type, <br /> pipiny, streets and adjacent properties (north toward the <br /> ttop off the page� location of nearby septic tanks, <br /> leachfields, buLidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> '-b' 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> `d" Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> NX 6. Procedures should explain decontamination techniques if <br /> appplicable, 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 /> /V Procedures should explain purging and/or inerting method. <br /> 8. Describe in detail how soil and/or water samples beneath the <br /> A tank's invert will be obtained. Refer to 11,13 11 Protocoln�/ <br /> ,l for Routine �T-apnk Removals" for <br /> f,�opr,�samcpili g c iterza: df� 64- <br /> 9. Aa pKJ <br /> s � Com to �� qU L �1 H� 1 �S 9�CO G• <br /> p the an Joa in oc ea th District's <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 /> ❑ 1 . Advance ins ction notice of at least 48 hours is reqLines caion no i >ca ion o �urLs is leiredsbw <br /> iedi�itona ci <br /> vanc <br /> contractor 's— onsibiliity_ <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468.3400 468-3030 468.3420 468-3860 <br /> Air Pollution Community Services Laboratory WIc <br /> 468.3470 468-3820 468-3460 468-3280 <br />