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• 0 <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres. SERVING <br /> Earl Plmentel,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 nipon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUN k�ING-FiAZAFFI5a0S MATER I ALS <br /> � Zi <br /> I. GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> ' 2. Include a detailed site map showing tank location and type <br /> iping, streets and atajacent properties (north toward the <br /> op off the page) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> �-,� (including water, sanitary sewer and storm sewer) . <br /> �3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> LIQ I Complete the "Authorization Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 3 6. Procedures should explain decontamination techniques if <br /> applicable, rnaterial(s) utilized for rinsate, transportation <br /> aria/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 /> 7 Procedures should explain purging and/or inerting method. d,( 3t /,060 <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 /> Routine Tank Removals" for sampling criteria. <br /> }j 9. Colete the San Joaquin Local Health District's (SJLHD) <br /> "Undmpperground 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 /> O 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> CD 11. Advance ins action notice of at least 48 hours is required by <br /> Lfie an , oa uin ocal—Aea is ric cProgria e a vance <br /> ins CT—,on no 1 lca ion oZ_j ru is is ionaT fire district is <br /> contractor A re�sponsibiliEy, <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health , <br /> 468-3400 Public Neal h Nursing <br /> 468-3830 468-3420 468-3360 <br /> Air Pollution Community Services Laboratory WI c <br /> 468-3470 468-3820 <br /> 468-3460 468-3280 <br /> eu'%c i <br />