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BOARD OF TRUSTEES SAN JOAO'UIN LOCAL HEALTH DISTRICT <br /> Al Crow,Pres, SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,5ec'y, 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 /> V,rginia 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 Stockton <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGRO WS MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> I. Submit all information in triplicate. USE CARBONS. <br /> 0' 2. Include a detailed site map showing tank location and type, <br /> fipinc , streets and adjacent properties (north toward the <br /> op of the page) location of nearby Septic tanks, <br /> leachfields, bulidin"Js and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> Ld3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 14. Complete the "Authorization to Release Analytical Data'" form. <br /> 5. Submit the appropriate fees and complete the '"U <br /> Tank Program Fee Worksheet'". p "Underground <br /> 16. Procedures should ex lain decontamination techniques if <br /> applicable, materialS) utilized for rinsate, transportation <br /> arid/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 /> Hd 7. Procedures should explain purging and/or inerting method. <br /> Q`_8. 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 Removals"' for sampling criteria. <br /> a 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 /> 0. The maximum <br /> from the dateeofereceriptfof thesadequatelyans icompletediPlan. <br /> 1.1. Advance ins ction notice of itt least 48 hours is re uire� <br /> E�ie^� a���uin Goia�� i s -r is ro r is e advance <br /> in cion no i - ra{ion of�uris zr_ iona ire is .ric is <br /> cont- or's resuor� ib> t v" <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health <br /> 468-3400 Public Health Nursing <br /> 468-3030 468-3420 469-3960 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 469-3820 468-3460 468-3280 <br />