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II OU w I1 "1✓lJT - <br /> �, TK <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Plmentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Most M.D. JOGI KHANNA, M.D., M.P.M., 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 /> UNDERGROUND S99TF=�MNG—RA'LAMMS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ 1. Submit all information in triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed site map showing tank location and type, <br /> pipincl, streets and adjacent properties (north toward the <br /> ttop off the page) location of nearby septic tanks, <br /> leachfields, ulidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> ❑ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <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 /> ❑ 6. Procedures should explain decontamination techniques if <br /> applicable, Inaterial(s) 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 /> ❑ 7. Procedures should explain purging and/or inerting method. <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 /> 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 thepermit shall. be responsible for ensuring that this form <br /> is completed arld 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 insRgction notice of et least 48 hours is required by <br /> Trie` n oa u>n oca�F�ealff�6>s�ic �prooria a vacT ance <br /> ins�ec�on no i ic' anion iuris fictional fireid strict is <br /> contractors respon5i i v, <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 488-3030 468.3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460.3820 468-3460 468-3280 <br /> AIDS Information 468-3620 <br />