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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At Crow,Pres. SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> APPLICATIO14 FOR PERMIT TO CLOSE <br /> UNDERGROUN ��S MATER I ALS <br /> _ <br /> I . GENERAL INSTRUCTIONS: <br /> l Submit all information in triplicate. USE CARBONS. <br /> L�ct' Z. Include a detailed site map showing tank location and type <br /> piping, streets and adjacent properties (north toward the <br /> top of the paged location of nearby septic tanks, <br /> leachfields, buifdintjs and underground public utility lines <br /> D4• (including water, sani�ary sewer and storm sewer) . <br /> � � Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> EP 4 Complete the "Authorization orization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> ITank Program Fee Worksheet". <br /> 3 6. Procedures should exlain decontamination techniques if <br /> applicable, material ) 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 /> 0Zwaste generated on site. <br /> 7. Procedures should explain purging and/or inerting method. �,Or 1040 <br /> 3ILe 8. Describe in detail how soil and/or water samples beneath the <br /> tanks invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> 3 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Tank Disposition Tracking Record". The holder <br /> of the permit shall. be respponsible 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 ins ction notice of at least 48 hours is re uired by <br /> I e an oaQuin ocal=Aea is ric ro ria e a vance <br /> ins c ion no i flea ion of-,ur1s ic7-c�ionaI" l�re� is -r—I is <br /> con rac or spons>bility_ <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Healtht <br /> Public Heal h Nursing <br /> 468-3400 <br /> 468-3830 468-3420 <br /> 468-3960 <br /> Air Pollution Community Services Laborato n <br /> 468-3470 ry WIC <br /> 468-3820 468-3460 468-3280 <br />