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1 1 <br /> BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> . ., SERVING <br /> At Crow,Pros. I <br /> Earl Plmentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy, Stockton, California 95205 City 01 Manteca <br /> James F.Culbertson <br /> John D.Mast M.D. City of EscaionJOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER Ci <br /> Virginia Lodi <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M. City of Tracy <br /> yof Ripon <br /> Daphne Shaw <br /> Harvey Williams,Ph.D. San Joaquin CountyCity of Stockton <br /> APPLICATION POR PERMIT TO CL OSF San Joaquin County <br /> UNDFRGROUND�"1ziFFk )+ IytpftlS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> M-1. Submit all information in triplicate. USE CARBONS, <br /> h1 2. Include a detailed site map showing tank location and type, <br /> pipincJ, streets and -adjacent properties (north toward the <br /> leachfie the <br /> ut. dlocation <br /> % landoundergrroundpublicnutility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUNp TANK <br /> CLOSURE", <br /> 4• Complete the "Authorization to Release Analytical Data" form. <br /> Fit r 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worpksheet". <br /> } 6• applicable,shnaterial(sjiutilizedaforarinsatechtransportation <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 /> Klu 7. Procedures should explain purging and/or inerting method. <br /> a-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 /> gl 9. Compplete the San Joaquin Local Health District's (SJLHD) <br /> ofnthegrpeornitrid ishalllbeoretpionsTblekfor ensuring that holder <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 insaction notice of at least 48 hours is re wired by <br /> T e <in oa uLn ocaI=Te i is ric <br /> ins cion rrotT at ion oT— ro rla -e a vance <br /> con rac or s'—res'ons 1 if ?uric is lona ire district is <br /> EH 23 040 <br /> REVISED 12/88 <br /> Adminlstrallon Clinical Servicos <br /> 460.3400 Environmental Health Public Health Nursing <br /> 468-3030 468.3420 <br /> Air Pollution468-3060 <br /> Community Services Laboratory <br /> 460-3470 460-3820 WIC <br /> 408-3460 468-3280 <br />