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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,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,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 /> UNDERGROUND STORAGE TANKS SMRING FUMMMS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ 1. Submit all information in triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed si.te 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, buiidings and underground public utility 11 es / <br /> (including wate�rx,' sanitary sewer and storm sewer) . k-oc f•vn wj( <br /> 3. Complete form <br /> IfQPL0N. FOR PERMIT FOR UNDERGROUND TANK <br /> �� CLO URE" iv czo <br /> i4- Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees an co plete the "Underground <br /> Tank Program Fee Worksheet". C -/-i V{A& <br /> Q 6. Procedures should explain decontamination techaniques 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 /> 3 waste generated on site. <br /> 7 Procedures should explaipurging and/or inerting method. <br /> Describe in detail how soi a /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 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 /> ❑ ].1. Advance ins ction notice of at least 48 hours is re fired b <br /> E e an oa uin oca Fr District. ro ria e a vane <br /> ins9gction notification of juris ir- ions ireid strict is <br /> con rac or s resoonsibiiity. <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 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />