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BOARD OF TRUSTEES PUBLIC HEALTH SERVICES 'T SERVING <br /> At Crow;Pros. San Joaquin County <br /> Earl Ptmentel,Vice Pres. San Joaquin County City of Manteca <br /> Tommy Joyce,Sec'y. ENVIROHMEHTAL HEALTH DIV. 468-3420 City ofEscalon <br /> James F.Culbertson 1601 East Hazelton Avenue City of Lodi <br /> John D.Mast M.D. Stockton, California 95205 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 /> UNDERQ2S MATERIALS <br /> �I GENERAL INSTRUCTIONS: <br /> Ud' 1. ubmit all information in triplicate. USE- 3. <br /> �I1 Include a detailed site map showing tank location and type, <br /> to <br /> ipinq streets and adjacent properties (north toward the <br /> O <br /> p of the page) location of nearby septic tanks, <br /> leachfields, 6ui`ldings and underground public utility lines <br /> (N 9d &iAIF water, Cn�a weer send 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) uti ized for rinsate, transportation <br /> a /or storage of hazardous waste-generate8 on site, and <br /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. Nar"+t�� uy AlasS,-eh <br /> Procedures should explain purgin and or inerting method. <br /> C1�8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> Zfor Routine Tank Removals" for sampling criteria. <br /> L99. 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 /> ❑ l Advance in ion notice of at least 48 hours is re iced b <br /> e an oa uin oca, FTea i District. ro ria e a vance <br /> ins cion notification o Jurisdictionaliredistrictis <br /> con rac or s responsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> oO�Z1i <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 480-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />