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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentei,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy, Stockton, California 95205 City or 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--S'= ` '7 S MATERIALS <br /> T. GENERAL INSTRUCTIONS: <br /> 11. Submit all information in triplicate. USE CARBONS. <br /> [?"'2. Include a detailed site map showing tank location and type, <br /> ipin streets and adjacent properties (north toward the <br /> op of the page� location of nearby septic tankst <br /> leachfields, bul,din<js and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> LSI 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> OVY5 f� 5. Submit the appropriate fees and complete the "Underground <br /> ;U Tank Prograk Fee Worksheet". <br /> R/6. Procedures should explain decontamination techniques if <br /> applicable, lnaterial(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. <br /> �X8 <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 /> U 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 /> [Y(10. <br /> f is completed and returned the SJLHD. <br /> [Y 10. The maximum review time for Closure Plans is 15 workingg days <br /> from the date of receipt of the adequately completed plan. <br /> Q/11. Advance ins ction notice of at least 48 hours is recruired b <br /> e an joaguin Local Health i5 ris ro ris e advance <br /> insoection `n�o i lca ion o lurrs lc lona ireis rlc is <br /> contractor 'sresponsibility. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration C:inical Services Environmental Health Public Heal!h Nursing <br /> 468-3400 468-3330 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 />