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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Selly. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Meet,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. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDS MATERIALS <br /> �(�I GENERAL INSTRUCTIONS: <br /> ijwj l Submit all information in triplicate. USE CARBONS. <br /> bV X2. Include a detailed site map showing tank location and type, <br /> piping, streets and adiacent properties (north toward the <br /> top of the page) location of nearby septic tanks, <br /> leachfields, u dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> v ® 3 Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> tv <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Data" form. L <br /> Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". s¢o -1,� -,p,- * <br /> 0� 6. 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. <br /> vv Procedures should explain purging and/or inerting method. <br /> vl <br /> V8. Describe in detail how soil and/or water samples beneath the <br /> tanks invert will be obtained. Refer to "Sampling Protocol <br /> 1 for Routine Tank Removals" for sampling criteria. <br /> 0'V LJ 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record". The holder <br /> of thepermit shall be responsible for ensuring that this form <br /> is completed arxJ 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. Nva ce 'ns tion notice of at 1 ast 48 hours is required b <br /> L e an oaquin Localea ric r ria e a vance <br /> i1 T:ion notifiea ion o �urlsdlc�lona eP is .ric is <br /> COntrartoY s responsiDility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468.3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 468-3460 468-3280 <br />