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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT Q , /SERVING <br /> AI Crow,Pres. <br /> Earl Pimantel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> City of Manteca <br /> Tommy F. <br /> , s 'y. Stockton, California 95205 City of Escalon <br /> James F. ,M.D.Culbertson Ciry of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> ThomVirgina Mathews City of Ripon <br /> Thomas Shaw D.V.M. San Joaquin County <br /> Daphne Shaw <br /> Harvey Williams,Ph.D. City at StocktonSan Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> LINDERg20UN S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> 9/2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> top of the pagge) location of nearby septic tanks, <br /> leachfields, buLidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> �i. Complete form IIAPPLICATIONFORPERMIT FOR ERG20UND TANK <br /> n <br /> CLO3 URE —�i6 <br /> i4 Complete the "Aut1rization to Rel ase Analytical Data" form. <br /> k 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> Procedures should explain decontamination techniques if <br /> applicable, material(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. 1�, <br /> j1j�z-Gid ��� GL%�S/✓✓ �CGL(�u`✓ G.y <br /> nod/7. Procedures should explain purging ar /or inerting method. <br /> [9 8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> � ��i for Routine Tank Removals" for sampling criteria. <br /> Ud 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 /> 0 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> I] 11.>Advance ins ection notice of at least 98 hours is re wired b <br /> uin oca <br /> L� an oa IFea Ls ric ro rta e a va_nce <br /> inspe�__c. ion no L ica ion o <br /> ori s response i auris Lc ions ire is xic is <br /> caitrac i v <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmenai Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 <br /> 468-3280 <br /> AIDS Information 468-3820 <br />