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ie <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRWtrXT SERVING <br /> AI Crow,Pres. PA Y M E N"I" <br /> RECEIVED C E I V E D San Joaquin County <br /> Earl Pimento[,Vice Pres. 1601 East Hazelton Avenue city of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson 0 C T - 19 P + City of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.O., M.P.X., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of ENVIRONMENTAL HEALTIsan Joaquin Coln <br /> Thomas Schubert D.V.M. y <br /> Daphne Shaw PEP.MIT/SERVICES City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERCROUN S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> Nps 2. Include a detailed site map showing tank location and type, <br /> is piping, streets and adjacent properties (north toward the <br /> Nt1tp,-� ttop of the page) location of nearby septic tanks, <br /> Uk leachfields, ui�dings and underground public utility lines <br /> / <br /> a (including water, sanitary sewer and storm sewer) . <br /> D\� [ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 0I1�- b 6. Procedures should explain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> acrd/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. <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 /> y V 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 the permit 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 /> 1 - 1.1. Advance ins ection notice of at least 48 hours is re iced b <br /> L e an Joaquin octal—Ilea is ric ro ria e a vance <br /> coo scion sor responsibility.liuris is Iona iredistrict is <br /> EH 23 040 <br /> REVISED 12/88 <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 />