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'BOARD OF TRUSTEES <br /> S JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. StocktonCalifornia 95205 City of Manteca <br /> , <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOG[ KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Shaw D.V.M. �DO qui of Ripon <br /> Daphne Shaw A / /�/1 ,/ San Joaquin County <br /> Harvey Williams,Ph.D. V v, - Oro lie City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUN S MATERIALS <br /> GENERAL, INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> 4Y2. Include a detailed site map showing tank location and type <br /> piping, streets and adjacent properties (north toward the <br /> ttop of the page) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, saniLry sewer and storm sewer) . <br /> 12'3. ., Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> - CLOSURE". <br /> L� 4. Complete the "Authorization to Release Analytical Data" form. <br /> ubmit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> appoliiccable,smateiial(sjlutalized decontamination techniques <br /> and/or storage of IiazardoLts waste generated on site, and <br /> specify the te�-ponsiite 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 /> Complete the San Joaquin Local Health District's (SJLHD) <br /> �� <br /> Underground Tank Disposition Tracking Record". The holder <br /> of the permit shall be respponsible for ensuring that this form <br /> is completed and returned -he 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. Advance ins ction notice of at least 48 hours is re ired b <br /> e an Oa Uln OCa ea is riC r0 ria e a Vance <br /> ins cion no 1 ica ion o IurIS lc lona iredistrict <br /> COn rar15 <br /> -� .�1u111L <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health , <br /> 468-3400 468-38� Public Heal h Nursing <br /> 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory <br /> 468-3470 468-3820 WIC <br /> 468-3280 <br /> AIDS Information 468-3620 <br />