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BGARD OF TRUSTEES JOAQUIN LOCAL HEALTH DICT SERVING <br /> �,Ai Crow,Pres. W San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escelon <br /> James F.Culbertson <br /> John D.Mast,M.D. City of Lodi <br /> JOGI KNANNA, M.D., M.V.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw d�/l L �,,_ / San Joaquin County <br /> Haney Williams,Ph.D. r/�.S/�"j(,J ���,� City of Stockton <br /> Sen Joaquin County <br /> APPLICATION FOR PERMIT lot?UNDERQ20tJN 641,101 <br /> // S MATERIA <br /> (SAI. INSTRUCTIONS: 5CU //. v�/01l M� <br /> �1. Submit all information in triplicate. USE CARBONS. <br /> F, 2. Include a detailed site map showing tank location and type, <br /> pipingq, streets and adjacent properties (north toward the <br /> ttop of the pa9a location of nearby septic tanks <br /> leachfields, bulidings and underground public utility lines <br /> (i eluding water, sanitary sewer and storm sewer) . <br /> y Y 3. mppTete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSlR2E". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> ❑ 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 4J' 6. Procedures should exxpplain decontamination techniques if <br /> applicable, material s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> 7 specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> td 7. Procedures should explain purging and/or inerting method. <br /> ❑ 8. Describe in detail how soil and/or water samples beneath the <br /> nk s invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> Compplete the San Joaquin Local Health District's (SJLHD) <br /> " nderground Tank Disposition Tracking Record". The holder <br /> Of the permit shall be responsible for ensuring that this form <br /> I completed and 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 /> 11. Advance ctio ce o at leas 8 o i ed b <br /> Adman <br /> oa uIn a s r>c DDronr>a e a vancP <br /> ins cuo no i ice ion <br /> or jurisdicr-lonalfire district is <br /> on ra r s responsigility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> MAY 2 41989 <br /> ENVIkUrdiVIENTAL HEALTH <br /> PERMIT/SERVICES <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 4683400 468-38W 468-3420 466-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3480 <br /> 486-3280 <br /> AIDS Information 468-3820 <br />