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BOARD OF TRUSTEES <br /> pr <br /> At Crow,pros. SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> SERVING <br /> Earl Tommy Joyce Vice Prea, 1601 East Hazelton Avenue San Joaquin County <br /> Jamess F.Culbertson Stockton, Calitornia 95205 <br /> James F.Culbertson City of Manteca <br /> John D.Masi,M.D. City of Escalon <br /> Virginia Mathews JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Thomas Schubert,D.V.M. City of Tracy <br /> Daphne Shaw City of Ripon <br /> Harvey Williams,Ph.D. San Joaquin County <br /> City of Stockton <br /> APPLICATION FOR PERMIT TO CLOSE San Joaquin County <br /> UNDE(2GROUN6 Z3'(IaTmp�Z.-r� ,� , <br /> n anrtuc�lS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ I. 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 the <br /> ttop of the page) location of nearby septic tanks <br /> leachfields, uiidlrnls and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> ❑ 3• Complete form "APPLICATION FOR PERMIT POR UNDERGROUND TANK <br /> CLOSURE", <br /> ❑ 4. Complete the "Authorization to Release Analytical Data" form. <br /> ❑ 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Pee Worksheet". <br /> ❑ 6. Procedures should expplain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> all storage of hazardous waste generated on site, and <br /> wastefgeneratedponssite party(ies) who will be disposing of <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 /> ❑ 9• Complete the San Joaquin Local Health District's (SJLfID) <br /> "Underground Wank Disposition Tracking Record". The holder <br /> of the permit shall he respponsible for ensuring that this form <br /> is Completed and returned t'lie 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 ction notice of z+t least 48 hours is re uir--ed by <br /> L e an oagtlin opal-pea_ <br /> ins c ion iTic 1`' 'ric re ria -e acvarnce <br /> con rap. or s res ons�eiIT[ iuriscfic Iona ire is .rip is <br /> F-H 23 <br /> REVISED412/88 <br /> Administration Clinical Services <br /> 460.3400 468-3030 Environmental Health Public Health Nursing <br /> 468-3420 468-3960 <br /> Air Pollution Community Services <br /> 468.3470 460.3820 Laboratory WIC <br /> 468-3460 468.3280 <br /> AIDS Information 4RR 4nin <br />