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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT SERVING� <br /> Ai Crow,Pres, San Joaquin county <br /> Earl Plmentel,Vice Pres, 1601 East Hazelton Avenue city of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> John D.Mast,M.D. <br /> James F.Cut,M.D. - City of Lodi <br /> JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County Harvey Williams,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE UNDERGROUN S MATERIALS <br /> I GENERAL Il information <br /> AqSubmit all information in triplicate. USECARInclude a detailed site map showing tank location , <br /> piping, streets and adjacent properties (north to ard ,t L $g <br /> GENERAL <br /> of the page) location of nearby septic tanks r f JALI:EALTH <br /> leachfields, uL�dings and underground public utility lines SRA��}iES <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. Compple e form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Da*tt``m, u � <br /> 5 Submit the appropriate fees and complete the "Underg <br /> Tank Program Fee Worksheet". ll+ 1 ^1989 <br /> Procedures should explain decontamination techniques i€ vTAL HEALTH <br /> applicable, material(s) utilized for rinsate, transportation. 7SERVICEs <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 /> Procedures should explain purging and/or inerting method. <br /> 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 /> 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of thepermit shall be responsible 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 98 hours is re fired b <br /> t e an oa 1n Localea is ric ro ria e a vane <br /> ins c ion no L Lca ion o �ur>s Lc Lona ire district is <br /> con rac or s resoonsi t L v <br /> EH 23 090 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Heath Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 468-3460 468-3280 <br /> AIDS Information 468-3620 <br />