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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> All Crow,Pres. San Joaquin County <br /> Earl Plmental,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 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 Shaw <br /> � City u Stockton <br /> Harvey Williams,Ph.D. <br /> /Q(J �, (�jQ4P/CU �1 �Y San Joaquin County <br /> APPLICATION FOR PERMIjl'� CLOSE <br /> UNDERGROUN RIP ZA(F6bDS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> CY2. Include a detailed site map showing tank location and type, <br /> iping, streets and adjacent properties (north toward the <br /> op of the pagge) location of nearby septic tanks, <br /> leachfields, bulidings and underground public utility lines <br /> �/j (including water, sanitary sewer and storm sewer) . <br /> Lf 3, Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 2/4. Complete the "Authorization to Release Analytical Data" form. <br /> ©�. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 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 /> 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 /> b 9Complete 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 inspection notice of at least 48 hours is re wired b <br /> Lt—ie an Joaquin Local ea t is rlc ro ria e a vance <br /> ins eC ion notification ot jurisuictional tire district is <br /> con rac or s resnon inii1ty <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3030 468.3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 408-3460 <br /> 468-3280 <br /> AIDS Information 468-3820 <br />