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4 <br /> IftoARo OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,ce,Sec' City of Manteca <br /> y Stockton, California gS205 <br /> James F.Culbertson City of Escalon <br /> John D.Meat M.D. City of Lodi <br /> JGGI K1IANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V,M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D, City of Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERQROUND . __.... S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ 1. Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type <br /> piping, streets and adjacent properties (north toward the <br /> ttop o the paged location of nearby septic tanks, <br /> le hfields, 92 din+ls and underground public Utilit_v lines <br /> including water, sanitary sewer and -torjn y`ewer) . , �u <br /> f4 Ce�icl�.e sTG?.vGG. lt.�rl� �1 <br /> Camplete�" forth "APPLICATION FOR P IT FOR UNDERGROUND TF�4 <br /> CLOSURE". w a-1-K s '� yLj-e d.le,e! <br /> 1+x' 4. mplete the "Authorization to Release Analytical Data" form. <br /> I� 5 Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". p ,ground <br /> 6. Procedures should alain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> ana/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 /> 7 Procedures should explain purging and/or inerting method. <br /> Describe in detail how soil and/or water samples beneath the <br /> tanks invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removais" for sampling criteria. <br /> g. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Tank Disposition Tracking Record". The holder <br /> of thepermit shall be res onsible for ensurin that this form <br /> is completed and returner] �he SJLHD. <br /> Q 1 <br /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> �.he <br /> vance ins ection notce of at least 48 hours is re uired by <br /> an oa uain oca Rea is ric ro ria e advance <br /> ins ec zon no i Pica >on o oras ir_ ionstiredistrict as <br /> cots ac ors res ons"ibirif <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Heafth Nursing <br /> 468-3400 468-3030 463-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 460-3820 408-3460 468-3280 <br /> AIDS Information 468-3820 <br />