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— r <br /> *N JOAQUIN COUNTY <br /> BOARD OF TRUSTEES PUBLIC HEALTH SERVICES �' SERVING <br /> Al Crow,Pres. EVVIRCNME'NTAL HEALTH DIVISION San Joaquin County <br /> Earl Plmenlel,Vice Pres. P. o. BOX 2'l09 �', City of Manteca <br /> Tommy Joyce,Sec'y. STOCKTON, CA 9520 i 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 ShawCity of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUNU-gTbTFAGE [�MTC-RKMMUS MATERIALS <br /> GETIERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> LTJ 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, buildings and underground public utility lines <br /> (including water, sanHary sewer and storm sewer) . <br /> L7 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Data" form. <br /> L7 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> P/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 /> L77. Procedures should explain purging and/or inerting method. <br /> 1'R1,8. 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. Advance ins ection notice of at least 48 hours is re uir-ed b <br /> theSanoa uin oca Ffea i District. roria e a vance <br /> con ractor so oonsibi ° Yiuris lc Iona ire is Sic is <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Heal!h Nursing <br /> 468.3400 468-JO30 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468.3820 468-3460 468-3280 <br /> AIOS Information 468-3020 <br />