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BOARD OF TRUSTEES <br /> At e:ow,Pres. S JOAQUIN LOCAL HEALTH DIS ICT <br /> Earl Pimentel,Vice Pres. SERVING <br /> Tommy Joyce,Secy 1601 East Hazelton Ave nue // <br /> James F. toCkton, California 95205 /f'/�'C San J Joaquin County <br /> Culbertson �� Ci of Manteca <br /> John D.Mast,M.Q. <br /> Virginia Mathews JOG( KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br /> City it EScalo i <br /> Thomas SchubertD.V.M. ity Of Lodi <br /> VM <br /> Daphne Shaw City of Tracy <br /> Harvey Williams,Ph.D. City of Ripon <br /> San Joaquin County <br /> ON POR PERMIT City Stockton <br /> UNDERt�OUtyiAPPLICATITO San Joaquin County <br /> CLOSE <br /> S MATERIALS <br /> SAL INSTRUCTIONS: <br /> Submit all information in tri <br /> 2/2. Include a detailed site S plicate. USE CARI30LVS, <br /> Veping, streets and adjacent showing tank location and type <br /> OP o the page) location Of nearby <br /> (north toward the ' <br /> leachfields, ueldings and undergroundptic tanks <br /> (encludIng water, sanlLar public utility lines <br /> Com y sewer and storm sewer) . <br /> 12/ CLOSURE", form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> 0 5. Submit the appropriate fees and complete the <br /> Tank Program Fee Worksheet". "Under <br /> ground <br /> 6. <br /> apProcedures should explain decontamination techniques if <br /> d%orasorag Material(s) utilized for rinsate trap <br /> specify the responsible generated on site, and <br /> waste generated on site. Y{1es) who will be disposingof <br /> E�7. Procedures should explain Purging g g and/or inerting method. <br /> 8. Describe in detail how soil and/or water samples bene <br /> tank 's invert will be obtained. Refer to "Sampling Pretocol <br /> for Routine Tank Removals" for sampling criteria, <br /> 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> Underground Tank Disposition Tracking Record". The ho <br /> of the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> y' ❑ 10. The maximum review time for Closure Plans is 15 workinq days <br /> from the date of receipt of the adequately completed Plan, <br /> 11, Advance ins ction notice of at least 4'8 hours is re aired b <br /> e an oa cti onens c ion no ica i�T`75e, i <br /> o ecro res e a vance <br /> con roc or s response 1 v. <br /> EH 23 040 <br /> REVISED 12/88 <br /> ZsJ <br /> Cool OF -3rd '3013BPI" <br /> 4' SP c-7—o S / c /-V/,� <br /> T� F196 <br /> Administration Clinical Services <br /> ces Environmental Heaith Public Health Nursing <br /> 468-3830 468-3420 <br /> Air PollutionCommunityServices Laboratory <br /> 468-3470 468-3820 WIC <br /> 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />