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C) F <br />BOARD OF TRUS SA/N� JOAQUIVLOCAL HEALTH <br />Al Crow, Pres. �,{�CCG2C% 1601 East Hazelton Avenue <br />Earl Pimentel, Vic <br />Tommy Joyce Secy. S ockton California 95205 <br />a .meq <br />DISTRICT SERVING <br />San Joaquin County <br />City of Manteca <br />�/�! y�- City of Escalon <br />James F. Culbertson J` {,rv� 9 ! �? Awot/� City of Lodi <br />John D. Mast, M.D.V/ JOGI KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER G"" V 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 />UNDERGIR S MATERIALS <br />GENERAL INSTRUCTIONS: <br />/1. Submit all information in triplicate. USE CARBONS. <br />B' 2. Include a detailed site map showing tank location and type, <br />piping, streets and adjacent properties (north toward the <br />op of the page) location of nearby septic tanks, <br />leachfields, buildings and underground public utility lines <br />E1/3. <br />/� (including water, sanitary sewer and storm sewer). <br />E1 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />044.Complete the "Authorization to Release Analytical Data" form. <br />U/5- Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet''. <br />[{, 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 />E�Zwaste generated on site. <br />�-7. ocedures should explain purging and/or inerting method. <br />B. 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 />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 />❑ 1.1 <br />The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />EH 23 040 <br />REVISED 12/88 <br />rc e �riL Q S� a� uS 0 H lr�caz•0� <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 468-3820 468-3460 468-3280 <br />AIDS Information 468-3820 <br />