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. • • Figw Coto/ <br /> A ' <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> San Joaquin County <br /> At Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,Vice Pres. City of Escalon <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Lodi <br /> James F.Culbertson MCi of Trac <br /> John D.Mast,M.D. JOGI KHANNA, M.D., .P.N., DISTRICT HEALTH OFFICER City of Ripon <br /> Virginia Mathews San Joaquin County <br /> Thomas Schubert,D.V.M. City of Stockton <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. <br /> APPLICATION FOR PERMIT S MATERIALS <br /> UNDERGROUNIS$9DFfA7ZIE�1�5 <br /> JJ I. GENERAL INSTRUCTIONS: <br /> (i4 11. Submit all information in triplicate. USE CARBONS. <br /> C?/"2'. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> top of the Pagel location of nearby septic tankst <br /> leachfields, bu>.idings and underground public utility lines <br /> 9'3. (including water, sani6ry sewer and storm sewer) . <br /> Complete form "APPLICATION FOR PERMIT F'OR UNDERGROUND TANK <br /> \ CLOSURE". <br /> a� 4. Complete the "Authorization to Release Analytical Data" form. <br /> 0U5. Submit the appropriate fees and complete the "Underground <br /> / Tank Program Fee Worksheet". <br /> 53 6. Procedures should exxpplain decontamination techniques if <br /> ap licable, materials) utilized for rinsate, transportation <br /> a /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 /> '7. Procedures should explain purging and/or inerting method. <br /> [� 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 /> E 9. Compplete 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 /> 5 10. The maximum review time for Closure Plans is 15 working days <br /> --// from the date of receipt of the adequately completed Plan. <br /> LTJ 11. Advance 'ns ction notice of at least 48 hours is re fired b <br /> 'he San oaauin Local ea is r c Drooria e advance <br /> ins ctionotification JUrisdicLiona ire is xic is <br /> contractor's resaons-slD111 :v. <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 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />