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90ARD OF TRUSTEES SA—M JOAQUIN LOCAL HEALTH pISI ICT SERVING <br /> Al Crow,Pres. ' / ,' San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce.Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John 0.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. �` l / San Joaquin County <br /> Daphne Shaw /I1 li (i City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATTON FOR PERMIT TO CI OSE <br /> UNDERGROUND--,'" bR ETWC -M MS MATERIALS <br /> I GENERAL INSTRUCTIONS: <br /> l�l' 1 Submit all information in triplicate. USE CARBONS. <br /> 4 2 Include a detailed site map showing tank location and type, <br /> pipincl, streets and adjacent properties (north toward the <br /> ttop off the paged location of nearby septic tanks, <br /> leachfields, ui dirnJs and underground public utility lines <br /> (1� 1� (including water, sanitary sewer and storm sewer) . <br /> Com Tete form 114PPPLICATION FOR PERMIT FOR UND GRO D TANK <br /> ctiogURE". . dS F 4a <br /> I <br /> 4. Complete�the _"Au mor zat to Blease Analytical Dat " form. Lam' <br /> ,.,_,� � K �V f -ern if L�u fC ,Z..� 1.-.�. e <br /> C4 5. Submit the appropriate fees and omplete the "l�nderground <br /> Tank Program Fee Worksheet". <br /> [P/1,6. Procedures should ex lain decontamination techniques if <br /> applicable, inaterial(s) utilized for rinsate, transportation <br /> and/or storage of hazardOLIS 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 methcxi. <br /> 8. Describe in detail how soil and/or water samples beneath the <br /> tank 's invert will tx- 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 /> "UndergrouNi 'Tank Disposition Tracking Record". The holder <br /> of the permit shall. he res onsible for ensuring that this form <br /> is omelet nreturn/t SJLHD. 'j�' �S cr,-" G s`�j � �� 711 <br /> ❑ 10. The maximum review , for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11 Advance inspection notice of at least 98 hours is re uired by <br /> L' e ,�n oa uin oca ea > District.- ropria -e -;;� vance <br /> ins eec ion notitica ion of curls iC iona ire is .r 1C is <br /> con -rl ar.tor s respun•s i i i -y <br /> EH 23 090 <br /> REVISED 12/88 <br /> DAVE COMBS <br /> Operations Manager <br /> CONSTRUCTION, INC. <br /> Class ^ �'Cen9= v� nss�s,c Phone 805/397-7236 <br /> FAX 805/836-8164 <br /> 4609 New Horizon•Suite k2 Ices Envltonmen nl Health t <br /> Bakersfield,CA 93313 r Public Heal!h Nursing <br /> 30 468-3420 468-3360 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3283 <br />