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SA N sJ O A Q U IN Environmental Health Department <br /> — COUNTY- <br /> - . In addition , the following information must be submitted within 30 days after the UST removal <br /> date: <br /> a . Analytical results : only results that come directly from a third party California certified <br /> laboratory with affixed chain of custody will be accepted by EHD <br /> b. UST Tracking Record Sheet and/or Tank and Piping Hazardous Waste Manifest <br /> c. Tank Closure Certification Form (DTSC Form 1249) <br /> d . Hazardous Waste Manifests for tank and any piping if applicable. <br /> e. Backfill Excavation Certificate <br /> 10 . Permit expires 180 days from the date of approval . If an extension to the expiration date is <br /> required , a written request must be submitted to this office prior to the expiration date. <br /> If you have any further questions, please contact me at (209) 468-3455. <br /> Thank you , <br /> YA <br /> Betty Ho, EHS <br /> Environmental Health Specialist <br /> Cc: ATTN: Leisser Mazariegos, City of Tracy, 333 Civic Center Plaza, Tracy, CA. 95376 <br /> 2 of <br />