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•;r- dtw S.s -+n.. -ritX.;'. ::;-.+.E"v:r;-�..r .e..F 'Y-� .Y.',i6=c��_�1"� �".�w«r' x '."'K-s�.�: ;`A'y i�:.+:w' �4,'a1q�i. <br /> -i .. 7 <br /> 4, %L <br /> SAN JOADC-IN COLON. i <br /> .BOARD OF TRU9TEES G'G_L I C HE.'U_TH n.C3ij I C_S ` I3ElIYlflff <br /> s Al COW.PnW E.%VjR::":MENTAL HEALTr' DI4i5:Cti son Joaquin cosy <br /> i Earl PlmenlK Vim Pres. Pic. SJX 2%0-9 Ciy of Wnfeca <br /> TOM"JoyM Secy. STOCK T.'"%, CA 95201 - hof 6CalOn <br /> es <br /> Jamf.Cwb.lbon my "Loth <br /> John D.blast MAS JOGI KHANNA. U.0, f�A.P�f., DISTRICT HEALTH OFFICER Coy of Tracy � <br /> V www iu l wws CM of ryAon <br /> Thomas ScrdAWt D.VJAL ' San Joaquin Cony <br /> ' Daphne Shaw city oI Srocmon <br /> Harrel►lAfilrianfs,Ph Q San Joaquin Cmmy <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UN ER OUND-S G S HAMI <br /> • I. GENERAL INSTRUCTIONS• <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed site map showing tank location and t , <br /> piping, streets and adjacent properties (north toward the <br /> top of the page) location of nearby septic tanks, <br /> ' leachfields, bui�dings and underground public utility lines <br /> (including water, saMary sewer and storm sewer). <br /> ❑ 3. Complete form "APPLIC.ATION FOR PERMIT FDR UNDERGROUND TANK <br /> CLOSURE". <br /> ' G�9: Complete the "Authorization to Release Analytical Data" form. <br /> d 5. Submit the appropriate fees and complete the '"Underground <br /> ' Tank Program Fee worksheet". <br /> ❑ 6. Procedures should a lain decontamination techniques if <br /> Mlicable, materials) utilized for rinsate, .transportation <br /> /or storage of hazard=s 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 nethod.. <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 /> "I1ndergroursJ 'rank Disposition Tracking Record". The holder <br /> of t1he permit shall be responsible for ensuring that this form <br /> is completed armi 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 /> t ❑ 11. Advance inspection notice of at least 48 hours is re it b <br /> i e San jod winLocal—F-ea_ i 01strict. A. oro ria e a vance <br /> ins ctiol <br /> n no i ira icon o auris ictiona ire ismer ct s <br />� concr�c oz ,s�pansi <br /> EN 23 040 <br /> REVISED 12/88 <br /> Administration C!.n!cal Sernces Enrimwner.al Her.11� P�bkic Hearth Nursing <br /> ' 468.3400 4E.8-ja30 468-3420 468.3960 <br /> Air Po11ubon Community Services Laoofetory WN' 243 <br /> 468-34)0 46b <br /> 460.3820 •:,<60 468-3253 3 <br />