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0 <br /> BOARD OF TRUSTEES SAN JOA4UIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. 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 City of Lodi <br /> John D.Most 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 S. Li� City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUN S MATERIALS <br /> L,.- GENERAL INSTRUCTIONS: <br /> L"4`1 / Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> fiistreets and adjacent properties (north toward the <br /> oppoi�nc ,the page) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, sani�ary sewer and storm sewer) . <br /> LI 'Z3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> / CLOSURE". <br /> 1/4omplete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, materials) 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 /> waste generated on site. <br /> Procedures should explain purging and/or inerting method. ! J�per;'' <br /> 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 <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 Pian. <br /> ,❑ 11.. Advance inspection notice of at least 48 hours is re wired b <br /> e an Joa guin Local Health ►.s ric ro ria e advance <br /> inspection notification oT iur>is is lona ireicTstrict is <br /> contractor 's sre c- s�nTBi I! v. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Env`";onmental Health Public Heal!h Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 466-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />