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oZ <br /> 1,5- /0, Q�Sll .�z� • ` ` 'L <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Plmentel,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 City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROS MATERIALS <br /> INSTRUCTIONS: <br /> 1 Submit all information in triplicate. USE CARBONS. <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 tanks, <br /> leachfields, bul dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> F lSa t. :Complete <br /> mplete form "WPLICATION FOR PERMIT FOR UNDERGROUND TANK D•K <br /> CLOSURE". �12GL5 ✓�82( �YnQ/Yw �UYV� Cm F% f-f— E)ltGne{t�'�7 �15/8 <br /> I9 <br /> Lt—CJS/44. the "Authorization to Release Analytical Data" form. <br /> El`5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 4G 6. Procedures should explain decontamination techniques if <br /> applicable, materials) 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 methal. <br /> Ld'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 /> Ld 9. Compplete 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 'ns ction notice of at least 48 hours is re wired b <br /> E e an oa win oca Health District. ro ria e a vane <br /> inscion no i ica ion o juris is lona ire is .ric is <br /> con rac or s responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> �-U12 A <br /> 37x%- e, F D Q Tf:-, <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 468-3460 468.3280 <br /> AIDS Information 468-3020 <br />