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14illl <br /> BOARD OF TRUSTEES SAN JOAMIN LOCAL HEALTH DISTR-.CT SERVING " <br /> Al Crow,Pros. San Joaquin County' <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> Virginia Mathews <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Thom City of Ripon <br /> Thomas Schubert D.V.M. <br /> Daphne Shaw San Joaquin County Hervey Williams,Ph.D. City of StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> 1 I. GENERAL INSTRUCTIONS: <br /> �1 1. Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> top of the page)) location of nearby septic tanks <br /> leachfields, buildirnls and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> l� 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> E!?'4. Complete the "Authorization to Release Analytical Data" form. <br /> Submit the ropriat fe Qes and complete the "Underground <br /> Tank Program Yca eet". <br /> 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. J <br /> Procedures should explain purging and/or inerting method. N*Ad � J <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 /> S� 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 the permit shall. be responsible for ensuring that this form <br /> is 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 nspectio notice of rt least8 hours is re it d by <br /> [� nuin oc FTe t s r>.c p ro r a e�a van P <br /> inspection no i ca ion of 3ur> ictionaltireis .r—frict is <br /> con rac _or s responsibility, <br /> EH 23 040 <br /> REVISED 12/88 <br /> T <br /> �Utunr\srJ'f <br /> CYG 74i (a r r�JCXJ -- <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460.3820 468-3460 468-9280 <br /> AIDS Information 468-3820 <br />