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la,.,1,arU OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br />San Joaquin County <br />At crow, Pres. 1601 East Hazelton Avenue City of Manteca <br />Earl Plmentel, Vice Pres. City of Escalon <br />Tommy Joyce. Secy. Stockton, California 95205 City of Lodi <br />James F. Culbertson City of Trac <br />John D. Mall M . JOW KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Ripon <br />Virginia Mathews P A Y N E iv i San Joaquin County <br />Thomas Schubert. D.V.M. RECEIVED City of Stockton <br />Daphne Shaw San Joaquin County <br />Harvey Williams, Ph.D. <br />APPLICATION FOR PERMIT TO CLOS)' �'^I <br />UNDERGROUN30S MATERI&.2i <br />ENVIRONMENTAL HEALTR <br />e2. <br />GENERAL INSTRUCTIONS: PERMITISERVICES <br />1. Submit all information in triplicate. USE CARBONS. <br />(A' Include a detailed site map showing tank location and type, <br />pipinc, streets and adjacent properties (north toward Re <br />top o the pa e) location of nearby septic tanks4 <br />leachfields, buildings and underground _public _utLlity_lnes <br />(including water, sanitary sewer and storm sewerT:- <br />❑ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE" . j) D E PR <br />Complete the "Authorization toRelease Analytical Data" form.We 51' <br />m G �`` <br />�I Submit the appropri a fees and complete the "Underground <br />` Tank Program Fee Worksheet''. 7 <br />OV6, Procedures should explain decontamination techniques if <br />applicable, material(s) utilized for rinsate, transportation <br />at 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 />7. Procedures should explain purging and/or inerting method. <br />Describe in detail how soil and/or water samples beneath the <br />tank's invert will be obtained. Refer to "Sampling Protocol <br />for Routine Tank Removals" for sampling criteria. <br />❑ go,ete the San Joaquin Local Health Distrkct SJAfD <br />PUnderground Tank Disposition Tracking Record". The holder <br />of the permit shall be restonsihle 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 />Advanceeiins�ctio�n notice of at least 48 hours is re it d b <br />6�3 <br />LFe anS Joa uin Local— ea IIs ric ro ria e a vane <br />inspec ion_no i ica�ionT—�urisdic�iona ire is .ric is <br />EH 23 040 <br />REVISED 12/88 <br />to ha"v�t� I <br />Administration Clinical Services Environmental Health <br />468-3400 468-3030 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />AIDS Information 468-3820 <br />No, <br />Public Health Nursing <br />468-3960 <br />WIC <br />468.3280 <br />