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BOARD OF TRUSTEES Sib JOAQUIN LOCAL HEALTH DIAICT <br /> Af Crow,Pros. /// SERVING <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. JOGI KHANNA, M.D,, M.P.H„ DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stocklon <br /> San Joaquin County <br /> APPTTON FOR PFRMIT TO <br /> UNDERGROUN�i f'(� nC;�''�A�K ?;'I`cSf� U] .�,'L�OA1 7S MATER I ALS <br /> I . GENERAL INSTRUC]'IONS: <br /> 8`1. Submit all information in triplicate. USE CARBONS, <br /> R 2. Include a detailed site map showing tank location and type, <br /> Qpinc�, streets and adjacent properties (north toward tt�e <br /> p of the 0age) location of nearby septic tanks <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> C 3. Com Mete form "APPLICA'T'ION FOR PERMIT FOR UNDERGROUND TANK <br /> CLO URE". <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 /> 06. Procedures should explain decontamination techniques if <br /> apl.icable, material(s) utilized for rinsate, transportation <br /> an /or storage of hazardous w ste generated on site, and <br /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> 0" 7. Procedures should explain purging and/or inerting method. <br /> §3" 8. Describe in detail how :soil .and/or waiver samples beneath the <br /> tank 's invert will be obtained. Refer to "Sampling Protocol <br /> for Routine `yank Removals" for sampling criteria. <br /> 0 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Dank Disposition Tracking Record". The holder <br /> of theE�er.mi t shall he responsible for ensuring that this; form <br /> is completed and returnedhe 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 /> 011. Advance ins ction notice of at least 48 hour, is re uir.e_d by <br /> 1�7e pan o,�gu to nca F) 1_ mo_07000t ro r xa t ar vtrlc�� <br /> irtsPec ion noti ica iron o `uriscfir i iona Are is ric : iS <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 <br /> ass-3eso <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />