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,o <br />900b OF TRUSTEES <br />.?J Crow. Pres. <br />Earl Pimentel. Vice Proa. , <br />Tommy Jiyce, Secy. <br />James F. Culbertson <br />John 0. Mask M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, PhD. <br />f <br />1601 East Hazelton Avenue <br />Stockton, Callfomia 95205 <br />JOQI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />SERVING <br />Son In County <br />City of Manteca <br />City or Escalon <br />City of Lodi <br />city of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Sftklon <br />San Joaquin County <br />APPLIChTION FOR PFmmrT TO CLOSE <br />1 � �' t�� •� 1� ��ift�`..t:L�i�iift���l►4` _ �a�Z��Cy4LY�t. s`►la:� r., t+�: ,_ <br />• •, " <br />1 - Submit all information in triplicate.' USE CARBONS. NOV.05 1990 <br />a3"2. Include a detailed site map shoving tank locationand try <br />t pe, <br />piping, streets and adjacent•..••-(norths • te <br />•r of - •_• r. _ • • _ • • i. <br />taand <br />(including water, sa i ry sewer and storm sever). <br />Q300"34 Complete form "APPLICATION FOR PERMIT FOR UNDERCROUND TANK <br />CLOSURE". <br />R Data" form. <br />appropriate •"Lkiderground <br />Program ee • <br />0 6. Procedures should explain decontamination techniques If <br />r,.slicable,,materialls) utilized for• <br />. ., <br />specifyai /or storage of hazardous waste generated on site, and <br />•<• r r. who vill-be disposing • <br />vasbe generated on site. <br />7. Procedimes should explain purging and/or inerting method.. <br />CY8. Describe In detail how soil and/or water samples beneath,,the <br />tank's invert will be obtained. Refer to IISA.nling.Protocol <br />for Routine Tank Removals" for sampling criter a. <br />0-1�9. Complete the San Joaquin Local Health District's (SJLHD) <br />"Underground Tank <br />ition Tracking Record". The holder <br />• - r- • +• • for ensuring that this form <br />is completed • returned the <br />13'10. The maximum review time for Closure Plans is 15 working days, <br />from the date of receipt of the adequately completed Plan. <br />W , • • • <br />REVISED 12/88 <br />Administration cifnlail <br />468'3400 468.36p 3420 <br />Air Pollution commitinityservim <br />468.3470 468• <br />AIMS 1AWRInItfin war 4R" <br />Public HeeiBi Nmft <br />468. <br />WIC <br />