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II GENERAL INSTRUCTIONS: <br />LN' 1. Submit all information in triplicate. USE CARBONS. <br />Cil 2. Include a detailed site 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, page) and underground public utility lines <br />(int ngwaterset sew oi=r aril ozmewgx ' c <br />❑ 3. mp a form "APPLI TION FOR PERMIT FOR UNDER D ANK <br />CLOSURE". <br />L�'9. Complete the "Authorization to Release Analytical Data" form. <br />Submit the appropriate fees and complete the "Underground <br />ink Program Fee Worksheet". <br />P rocedures 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 />waste generated on site. <br />7. Procedures should explain purging and/or inerting method. <br />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 />❑ 9.Complete the San JoaquinLocal 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 Pian. <br />❑ 1 Advance ns etion notice of at least 98 hours is required by <br />EFe aS n Jw t>n oca�F�ealth is-ric Qproor>a�advaTce <br />EH 23 040 I- <br />REVISED 12/88 <br />OCT 02199vvv0 <br />Administration <br />Clinical Services <br />/.3Y7s I a C o✓ce� <br />4e8-3030 <br />Air Pollution <br />Community Services <br />468.3470 <br />460-3820 <br />SAN JOAQUIN COUNTY <br />BOARD OF TRUSTEES <br />PUBLIC HEALTH SERVICES <br />HEAL <br />AI Crow, Pros <br />ENVIRONMENTAL HEALTH DIVISION <br />SERVING <br />San Joaquin County <br />Earl FaPimentel, Vice Pres. <br />P.O. BOX 2009 <br />/� <br />City <br />City of Maolate <br />Tommy Secy. <br />CR 95201 <br />City of Escalon <br />James F.. CulbCine enson <br />City of Lodi <br />John D. Mast, M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />City of Tracy <br />Virginla Mathews <br />City of nipon <br />Thomas Schubert, D.V.M. <br />San Joaquin County <br />Daphne Shaw <br />City of Stockton <br />Harvey Williams, Ph.D. <br />San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGd20 <br />S MATERI S <br />II GENERAL INSTRUCTIONS: <br />LN' 1. Submit all information in triplicate. USE CARBONS. <br />Cil 2. Include a detailed site 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, page) and underground public utility lines <br />(int ngwaterset sew oi=r aril ozmewgx ' c <br />❑ 3. mp a form "APPLI TION FOR PERMIT FOR UNDER D ANK <br />CLOSURE". <br />L�'9. Complete the "Authorization to Release Analytical Data" form. <br />Submit the appropriate fees and complete the "Underground <br />ink Program Fee Worksheet". <br />P rocedures 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 />waste generated on site. <br />7. Procedures should explain purging and/or inerting method. <br />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 />❑ 9.Complete the San JoaquinLocal 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 Pian. <br />❑ 1 Advance ns etion notice of at least 98 hours is required by <br />EFe aS n Jw t>n oca�F�ealth is-ric Qproor>a�advaTce <br />EH 23 040 I- <br />REVISED 12/88 <br />OCT 02199vvv0 <br />Administration <br />Clinical Services <br />468.3400 <br />4e8-3030 <br />Air Pollution <br />Community Services <br />468.3470 <br />460-3820 <br />-WROMMENTAL HEALTf' <br />PERMITISER`JICF" <br />Environmental Health <br />468-3420 <br />Laboratory <br />466-3460 <br />Public Health Nursing <br />466-3860 <br />WIC <br />466-3280 <br />