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F� , <br /> . z <br /> e <br /> DOARO Olt TRUSTEES SAN JOAQUIN LOCAL HEALTH C TRICT <br /> AI Crow,Prea. SERVING <br /> "'• Earl Pfinentel,Vice Prot 1801 East Hazelton Avenue tin Joaquin County <br /> Tommy Joyce,sec'y' Stockton,Calltornis 95205 City of Monlece <br /> 4aa Jernec F.Culbertson City of Escalon <br /> John D.Mast M.D. JOFif KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Vlrgfnla Mathews\ CJty of Tracy <br /> Thomas Schubert I*m, City of nlpon <br /> Daphne Shaw •, San Jaaquln County <br /> Harvey Wlrfiams,PhD. Clty of Stockton <br /> Sen Joaquin Count <br /> PLICATIOfJ PERMIT TO CLOSE <br /> 0 $ <br /> GWERAL INSTRUCTIONS: <br /> • submit all inforfmaklon In trip lcate, USE CARBONS. <br /> 2. Include a detailed e map showing tank location and type <br /> Flpin , streets and adjacent properties (North toward tFre r <br /> top o the page) location of nearby septic tanks <br /> leachfields, u dings and underground public utility lines <br /> / (including water, sanitary sewer and storm sewer). <br /> (� . Compllete.form "APPLICATIOti FPERMIT FOR UNDERGROUND TANK <br /> } Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Under round <br /> Tank Program Fee Worksheets'. 9 <br /> �• Procedures should ex <br /> lain decontamination techniques if <br /> ap licable, material utilized for rinsate transportation <br /> a /or storage of hazardous waste generated 'on site, and <br /> r specify the responsible party(ies) who will be disposing of <br /> generated on site. <br /> 1�6jq E . Procedures should eapiain purging and/or inerting method. <br /> e. Describe In detail. how Boll and/or water samples beneath the <br /> tank's Invert will be obtained. Refer to "sampling <br /> Protocol <br /> for Routine Tank Removals" for sampling.crlteria, . <br /> l� 9. Complete the San Joa <br /> "Underground Tank Disposition rackiiigD ecordt.ta he h der <br /> of the permit shall. be responsible for ensuring that this form <br /> is completed aivi returned the SJLHD.' <br /> dl 1 The maximum review time for Closure Plans Is 15 works <br /> from the. date of receipt of the adequately completed Pan. <br /> ns ctio notio a 8 u <br /> u o c r <br /> np=an to ca ono u is <br /> 040 <br /> REVISED SE 12/88 <br /> ti <br /> Administration <br /> 488-3400 Clinical Sarvfcee Environmental Healtha-3a3o 48&3420 Public Health Nursing <br /> tlutlon 488-3860 <br /> Afr Po <br /> CoMrZnliy Services Labora[ory �- <br /> 488-3410 488.3820 WIC <br /> 408-3486 488-3280 <br />