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i <br /> Crow OF TRUSTEES <br /> " SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> AlAI Crow,Pres. San Joaquin County <br /> Earl yJoyce 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.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> ThomaVirginiMathews City of Ripon <br /> Thomas Schubert,D.V.M. <br /> Daphne Shaw San Joaquin County Harvey Williams,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE UNDERGROIRJ S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> 1. Submit all information i triplicate USE CARBONS. <br /> 2. Include a detailed site ma wig tank location and type, <br /> piping, streets and a iacent properties (north toward the ns9- <br /> top of 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 /> 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 /> 6. Procedures should explain decontamination techniques if <br /> ap licable, materials) utilized for rinsate, transportation <br /> a /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 /> 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 /> 11. Advance inspection notice of at least 48 hours is recluired b <br /> e San joaauin oca ea is rtc ro ria e a vane <br /> ins c ton no t tca ion o Hurts tc lona ire is rtc is <br /> contractor's responsibility. <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 <br /> 488-3280 <br /> AIDS Information 468.3820 <br />