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- ZX0 of TRIATEU SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Aa Crony,Prm San Joaquin County <br /> eo Plmurtol Vi"Pra& 1501 East Hazelton Avenue city of Mvnloca <br /> TMJ•tea e+cy Stockton,California 95205 ciy of Ewalon <br /> Jamie$F.CLJMlw City of Lodi <br /> Mn D.MsA KM J001 NHANNA, M.D., MAK, DISTRICT HEALTH OFFICER City of Tracy <br /> MA94w8 City of nlpon <br /> Tremas flctwbw%D.VM. San Joaquin Count' <br /> Daptm Shaw City of Si"kiw <br /> Ha"Y V4f TkJh Ph.D. San Joaquin County <br /> APL -TION FOR PERMIT TO CLOSE <br /> 2 <br /> INSTRUCTIONS; <br /> -1 Submit all information in triplicate. USE ChRMNS. <br /> Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> f fop of the pa location of nearby septic tanks <br /> leachfields, bulidin s and underground public utility lines <br /> /�, /�} (including water, sanifary sewer and storm sewer). <br /> ( ftp . Complete form "PPLICATIQN FOR PERMIT FW UNDERGROUND TANK <br /> ��•� <br /> ��/� j(,tr,fla�s LL��(Ga-n fc rr.a�rw X rc- rtt� 7o rS/s?� <br /> ;h� 4 Complete the "Authorization to Release Analytical Data" form. <br /> --5- Submit the appropriate tees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 4d 6• Procedures should ex lain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> ana/ar storage of hazardous waste generated on site, and <br /> . .r,f specify the responsible party(fes) who will be disposing of <br /> waste generated on site. <br /> L1�d'T, Procedures should explain purging and/or inerting method. <br /> i�`t' 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 /> Lef 9. Complate the San Joaquin Local Health Distric=t's (SJLHD) <br /> "Underground Tank Disposition Tracking Recot:d". The holder <br /> of the permit shall. be resrnsible. folr ensuring that this form <br /> is completgd•ani returnee! the SJLHD. <br /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> m <br /> j from the date of receipt of the adequately completed Pian. <br /> ❑ 11. e t tice n <br /> F a o xc saR houxr is sx. >uir b <br /> yt -,5 lvance <br /> i <br /> E1 23 040 <br /> REVISED 12/e8 <br /> �S t s"AP�W int, Tip/ -�. <br /> Atlm3nlalrallai Clinical sa ica7 Environmental Haralh Public Haalln Nursing <br /> 48b-34M 4e8-3030 468.3420 468.M&D <br /> AJr Pblfuution Commui*ServlCO3 Ln4oratory "I r' <br /> 468-:410 460-3f320 408.3460 468.3280 <br />