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�RD <br />OF TRUSTEES <br />S•JOAQUIN LOCAL HEALTH DIS•CT <br />SERVING <br />San Joaquin County <br />Al Crow, Pres, <br />1601 East Hazelton Avenue <br />City of Manteca <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce, Secy. <br />Stockton, California 95205 <br />City of Escalon <br />City of Lodi <br />James F. Culbertson <br />John D. Meso, M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />City of Ripon <br />Virginia Mathews <br />San Joaquin County <br />Thomas Schubert D.V.M. <br />City Stockton <br />Daphne Shaw <br />u <br />San Joaquin County <br />Harvey Williams, Ph.D. <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUN R� S MATERIALS <br />I. GENERAL INSTRUCTIONS: <br />D 1. Submit all information in triplicate. USE CARBONS. <br />[�2. Include a detailed site map showing tank location and type, <br />piping, streets and adjacent properties (north toward tTie <br />top of the page) location of nearby septic tanks, <br />leachfields, bLI dings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />1lV3. Cgmp61 to form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />4,1/ Complete the "Authorization to Release Analytical Data" form. <br />5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />❑ 6. Procedures should explain decontamination techniques if <br />applicable, materials) utilized for rinsate, transportation <br />an storage of hazardous waste generated on site, and <br />pecify the responsible party(ies) who will be disposing of <br />waste generated on site. <br />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 />❑ 9. 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 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 />❑ 11. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3630 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3620 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />W11- <br />468-3280 <br />IC468-3280 <br />