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1--A#D OF TRUSTEES S". M <br />JOAQUIN LOCAL HEALTH DIS -'CT <br />' <br />At Crow, Pres, <br />Earl Pi nentel, Vice Pres. 1601 East Hazelton Avenue r /�, 01cr <br />Tommy Joyce, Secy. Stockton, California 95205 <br />James F. Culbertson <br />John D. Mast, M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUN5—gTMACE--TANKS--gTC5 TgnTKZAR MS MATERIALS <br />��I GENERAL INSTRUCTIONS: <br />C1 1. Submit all information in triplicate. USE CARBONS. <br />�2. Include a detailed site map showing tank location and t <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />e <br />piping, streets and adjacent properties (north toward t e <br />top of the page) location of nearby septic tanks, <br />leachfields, I�uiidin(js and underground public utility lines <br />(including water, sanitary sewer and.storm sewer). <br />Ef 3. Complete form "APPLICATION FOR PERMIT ICOR UNDERGROUND TANK <br />CLOSURE". <br />0'4. Complete the "Authorization to Release Analytical Data" form. <br />a'5. Submit the appropriate fees and complete the "Underground <br />Tank Program I'ee Worksheet". <br />B 6. Procedures should ex lain 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 />B' <br />Procedures should explain purying and/or inerting method. <br />Describe in deL-ail how 'moil 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 (SJLIiD) <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 SJL14D. <br />The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />