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SAN JCT SERVING <br /> OAQUIN LOCAL HEALTH DISTRI <br /> BOARD OF TRUSTEES San Joaquin County <br /> Al Crow,Pre*. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimento[,Vice Pres, Stockton, California 95205 City of Escalon <br /> Tommy Joyce,Secy. City of Lodi <br /> James F.CulbertsonCity of Tracy <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.M., DISTRICT HEALTH OFFICER City of Ripon <br /> Virginia Mathews San Joaquin County <br /> Thomas Schubert,D.V.M. ✓ �� / <br /> Daphne Shaw City of Stockton <br /> 0 <br /> Harvey Williams,Ph.D. San Joaquin County <br /> '��tG i'"��' 1�b VT/ <br /> APPLICATION FOR PFRMIT TO CLOSE S _ 1���+ (�il <br /> UND <br /> I , iZ,FiERAi, INSTRUCTIONS: 11 1989 <br /> IL—J/1/ it all information in triplicate. USE CARBONS, p:,J: i A •�E i N <br /> . Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> top of the page) location of nearby septic tanksi <br /> leachfields, bui`idings and underground public utility lines <br /> /,(including water, sani�ary sewer and storm sewer) . <br /> LY3. Compplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> �CLOSUREmplete. <br /> mplete the "Authorization to Release Analytical Data" form. <br /> 1d�5. S it the appropriate fees and complete the "Underground <br /> ank Program Fee Worksheet". <br /> 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 /> cify the responsible party(ies) who will be disposing of <br /> :aZ,,-�r,ocedures <br /> generated on site. <br /> should explain purging and/or inerting method.ibe in detail how soil and/or water samples beneath the <br /> invert will be obtained. Refer to "Sampling Protocol <br /> Routine Tank Removals" for sampling criteria. <br /> 9. Com lete the San Joaquin Local Health District's (SJLHD) <br /> "U erground Tank Disposition Tracking Record". The holder <br /> the permit shall be respponsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> 0. 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 ins2gction notice of at least 98 hours is re iced b <br /> L e an oa u>n oca ea is r>c ro ria e a vance <br /> ins tic ion no i ica ion o Jurisdictionalire is .ric is <br /> con rat or s resoonsi > i y. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 466.3400 468.3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 480-3820 468-3460 468.3280 <br /> AIDS Information 468-3620 <br />