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ti <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,sec'y. Stockton, California 95205 City of Escalon <br /> City of Lodi <br /> James F.Culbertson <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 /> UNDERGROUNDMa-Cff-m-AN{C9-9'I`ZSR=T VUr)O7S MATERIALS <br /> I . GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> ppiping, streets and adjacent properties (north toward the <br /> iop of the page) location of nearby septic tanks <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 0"' <br /> 3. Complete form "APPLICATION ICOR PERMIT ICOR UNDERGROUND TANK <br /> CLOSURE". <br /> C 4. Complete the "Authorization to Release Analytical Data" form. <br /> Fa' 5. Submit the apropriate fees and complete the "Underground <br /> Tank Program Pee Worksheet". <br /> E G. 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 /> Il 7. Procedures should explain purying 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 Flealt:h District's (SJLI-ID) <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 /> L� 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 insDection notice of at least 48 hours is re uir.ed by <br /> -- e Sar oa u t n oca ea > is r is ADD r is-e advance <br /> insoection notification o . 'uric ic-iona ire district: is <br /> contractor's iTb i I iy. <br /> EH 23 040 <br /> REVISED 12/88 <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 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />