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PUBLIC HEALTH SERVICES iiii,,,iiiiir '? <br /> SAH JOAQUIN COUNTY SERVING <br /> BOARD OF TRUSTEES San Joaquin <br /> • <br /> All Crow,Pres. P. O. sox 2009 q County <br /> Earl Pimento],Vice Pres. (1601 East Hazelton Avenue) City of Manteca <br /> Tommy Joyce,5ec'y. <br /> Stockton California 95201 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 /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams.Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUN S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> 1. Summit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed si.te map showing tank location and tv0e, <br /> ?ipiny, streets and adjacent properties (north toward the <br /> op o 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 /> 15. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 6. Procedures should explain 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 /> L� 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 thep�rmi.t shall. be res onsible for ensuring that this form <br /> is completed and returned he SJLHD. <br /> ❑ 10. The maximum review time for Closure Plans is 15 workin days <br /> from the date of receipt of the adequately completed Plan . <br /> ❑ 11. Advance inspection notice of at least 48 hours is re iced b <br /> the San Joaquin Local HeaiEh District—. roriaeavance <br /> ins ec ion no z ica ion o t juris is ions ire iscT' trict is <br /> con -rac or ssresoons—iSiTily. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Sen-ices 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 468-3280 <br /> AIDS Information 468-3820 <br />