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ao,f;o cF;RUSTEES SAN ,AQUN LOCAL HEALTH DISTRI1,,' SERVING <br />A tow Pres. San Joaquin County <br />Ear! FI nem.r;l,'Ace Pres. 1601 Last Waken Avenue City of Manteca <br />Tom,gy Jeyes, Secy. Stockton, Caiilornia 95205 City of Esealon <br />Janne:; F. ,.ulbertson - City of Lodi <br />Wn a a1aa MD. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />Vif,'9.? 61au,ews City of Ripon <br />Too:nas.Schubart, D.V.M. _ San Joaquin County <br />Daphne Shaw �O f� f / — o /f 5:1010 J Jl m h"(d L City of Stockton <br />Harvey 4'dil AM% Ph. D. CY (/ [� l" J� �'+!,! ' I San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />JNDERGROUMIS SYOT??GE TAPaKB S' "iRIT1 �fTA�APXA7S MATERIALS <br />GENERAL INSTRUCTIONS <br />_. Submit all information in triplicate. USE CARBONS. <br />2. Include a detailed site nap showing tank location and type, <br />pioing, streets and,adjacent properties (north toward the <br />fop of the page) location of nearby septic tanks <br />leachfields, buiidings' and. underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />F--!(3. Complete form "APPLICATION FOR P'ER.MIT FOR UNDERGROUND TANK <br />CLOSURE". <br />❑ 4. Complete the "Authorization to Release Analytical Data" form. <br />5. Submit the appropriate Cees and complete the "Underground <br />,( Tank. Program �'ee Worksheet:,, <br />[L 6. Procedures should explain decontamination techniques if <br />applicable, material(s) utilized for rinsate, transportation <br />anb/or storage of hazardous waste generated on site, and <br />-peculy the responsible party(ies) who will Le disposing of <br />waste generated on site. <br />U✓ 7. Procedures should explain purgi"g rend/or inerting method. <br />✓I 8.riC in detail how soil and/or water samples beneath the invert will be ob'-:i.ned. Refer. to "Sampling Protocol <br />for Routine Tank Removals" Lor sampling Criteria. <br />9.y1Com�ilete the San Joaquin Local Health District's (SJL!D) <br />"Un_arground 'Tank Disoosition Tracking Record". The holder <br />Of the I..)ermit st:ali be rcsr onsible for ensuring that: this form <br />is completed and returnal 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 ins tion notice of at`least 48 hours is glired tv <br />Lhe an oaauin Soca-A.=aR1 ii_—A roL Soto ;3civance <br />_nom .ion no�ficarion _u?—`uri:;(1F-:iona - e isTricc <br />Con-rm or o rt:SD^n:91)'il ). Lam_ <br />EH 23 040 <br />REVISED 12/88 <br />Tl� ��'F T<r�,,_-.�1 o;•�:z ,�:-,,, J%aP�/PC�a.Li / C�-��uoa—fb'93a3 <br />Y-1 <br />l�r.!� �.`� N"• !-� � ?!i `_SFt.a j-�.c:/,�.� ;/ 1�;.-'O�J%:/f/tet <br />Fc TJnigWor, <br />46E 34,7E <br />Air Pollution <br />406-3470 <br />Cllnlow Serous <br />468-3030 <br />Communily Swvicen; <br />468-3820 <br />Environmental Health <br />468-3420 <br />.. -,y,",oq AIDS InfnmOnr 460"3080 <br />La no re.tory <br />453-3450 <br />Public Healtn Nursing <br />460-3850 <br />wn <br />468-32.10 <br />