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�V l <br /> L <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT; SERVING <br /> Al Crow,Pres, San Joaquin County <br /> Earl Pimentel,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John 0.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 /> UND 0 S MATER T ILLS <br /> I GENERAL INSTRUCTIONS: <br /> Submit: all information in triplicate. USE CARBONS. <br /> U2. Include a detailed site map showing tank location and t , <br /> piping, streets and adjacent properties (north toward the <br /> top of the page) location of nearby septic tanks, <br /> leachfields, bbuiidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 13" 3"' Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> Q 5. Submit the appropriate fees and complete the '"Underground <br /> Tank Program Fee Worksheet". <br /> I3 6. Procedures should ex0lain decontamination techniques if <br /> applicable, inateriai s) utilized for rinsate, transportation <br /> an 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 /> C ' 7. Procedures should explain purging and/or inerting method. <br /> D 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 /> L '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 /> is completed and returned the SJLHD. <br /> l0. a maximum review time for Closure Plans <br /> i5 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> 11. Advance 'ns ection notice of at least 48 hours is re uired b <br /> San JMuin-Local Heaitnis ric pflrOprl3 e advance— <br /> A jurisdictionai tire district is <br /> co a Or lEls O, s 1 1 1 . <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental health Public Health Nursing <br /> 468-3408 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory Wfr, <br /> 468-3470 488-3820 468-3460 468-3280 <br />