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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 city or 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 /> UNDERGROUN �S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> Q/2. 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, buildings and underground public utility lin s <br /> G�4 pLI- (including water, sanitary sewer and storm sewer) . * k�(r I oc..4icw5 <br /> C eVi 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4 Complete the "Authorization to Release Analytical Data" form. <br /> 4d 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> Procedures should explain decontamination techniques if <br /> mlicable, materias) utilized for rinsate, transportation <br /> l <br /> /or storage of hazardous waste generated on site, and <br /> specify the responsible-party(ies) who will be disposing of <br /> } �p�dr waste generated on site. <br /> C,or<t,' U 7. Procedures should explain purging and/or inerting method. <br /> V IA <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 /> Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder v+ <br /> of the permit shall be responsible for ensuring t t th}s fppgm <br /> �� is completed and returned the SJLHD. Coni deCodl ✓IaT►o n O FJ1 <br /> Lid 10. The maximum review time for Closure Plans is 15 working days �P�feS <br /> Q/ from the date of receipt of the adequately completed Plan. <br /> 11. Advance ins ction notice of at least 48 hours is re wired by <br /> --6 a an oa in oca ea is r c ro ria e advance <br /> CD n <br /> in, cion no > ica ion o ur>s >c ika ire is ric s " <br /> 23 0 rac ors response > i v. Ob�it,l F �, roV of- CfoSW'L-fid-/ 40_) <br /> 1 EH 23 090 1 <br /> REVISED 12/88 <br /> oche, $ofl bo S wi11 not be. re9LAif'r under- �� <br /> 000CAL U✓)feadel +oLnK Prior closure-��►-P /ace dv� <br /> 4V docurncnf,d soil cosi -a-rnirlaf►'on on sife� which was <br /> diSCover cOL 11- 3 —Y'G whe+'I /,000 GAL- fej1)la '' 'K Loa_5 <br /> rerr'ovecU t}I 14( rmcr +0LAk ioccL+ionS Sha it adf sseo( <br /> w hen4-h4- ll -r-1 vi r,fc( si-f-e cissa 155fV 7t i s PCt-_FDrrn <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 />