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I <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Af Crow,Pres. San Joaquin County <br /> Earl Mmentel,Vlce Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.O. 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. .�(� Yl�lt(�L� t� �/[(�YLt.��yi� San Joaquin County <br /> Daphne Shaw !/- S.1 City of Stockton <br /> Harvey Williams,Ph.D. ��� rLf%G� �'� San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGRgBS MATERIALS <br /> GENERAL INSTRUCTIONS- <br /> 2/.111 <br /> Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, <br /> �ipinq, streets and adjacent properties (north toward the <br /> Vopo the paged location of nearby septic tanks <br /> Y,,1; leachfields,page), <br /> din'jt and underground public utility lines <br /> (including water, sarni�ary sewer and storm sewer) . <br /> 3 Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Co let e� uthrizifvrivtcx.�,o'tnelce'!a� tical Data' SformZ�. <br /> or <br /> po <br /> FprindcpeAtre <br /> te ' ndergroundSubmit the h <br /> Tank Program ee <br /> 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 re-possible party( ies) who will be disposing of <br /> waste generated on site. <br /> VlwJ Procedures should explain purging and/or inert:ing methtxl. <br /> 8, . 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 /> Compplete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Tank Disposition Tracking Record" . The holder <br /> ofthe permit shall b respponsible for ensuring that this form <br /> is completed and returned !he SJLHD. Fj en ae 640,56-4 4A�,-W <br /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> frothe date of receipt of the adequately completed Pian. <br /> ❑ 1.1. Ldvai-nce ins ection notice of at least 48 hours is re uiredd by <br /> an �oa_c�t2inoca£�F{ea isa ric rr� ria e a vanceins�ec _Ion notifica .ion o 7uris ir_ LanaT fire dislric is <br /> contractor 'sr?sDonsFj jjty <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br />