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SCARO OF TRUSTEES Sd•JOAOUIN LOCAL HEALTH DIST RVL. <br /> At Crow,Pres. San Joaquin Counry <br /> Earl Platonist,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton,Celitornla 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 Show City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGRQUND--91V=EM=MffU9jMMXS MATERIALS <br /> GENERAL INSTRUCTIONS! <br /> Gd 1. submit all Information In triplicate. USE CARBONS. <br /> Lil�L• Include a detailed site map showing tank location and tyype, <br /> piping, streets and ad7•acent properties (north toward the <br /> L-op of the page)) location of nearby septic tanks, <br /> leachfields, bulgydings and underground public utility lines <br /> // (including water, sanitary sewer and storm sewer) . <br /> Ll 3. Complete form "APPLICATION iYTR PERMIT FOR UNDERGROUND TAM <br /> � CLOSURE". <br /> a- Complete the "Authorization to Release Analytical Data" form. <br /> I1Y5. Submit the apppropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> a 6. Procedures should explain decontamination techniques If <br /> applicable, 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 /> UY 77 Procedures should explain purging and/or inerting method. <br /> pyB. 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 /> Be9. Complete the San Joaquin Local Health District's (SJLFID) <br /> "Underground '1'ahk Disposition Tracking Record". The holder <br /> of the permit shall he responsible for ensuring that this form <br /> is completed acid returned the SJLHD. <br /> 0 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 ihsU rtion notice of at least 48 hours is re uired by <br /> E if a San Toaau in oca ea i 1-tr is DuroDF is ega3vari e <br /> insE or no i ica ion o uric Lc Iona ire i�icf is <br /> con a res Do nsiJi t i <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468.3400 468.3830 468-3420 468-3060 <br /> Air Pollution Community Services Laboratory Wic <br /> 468-3470 468-3820 468.3460 468-3280 <br /> AIDS Information 468-3820 <br />