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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEACTH DT ICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Plmentel,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 D.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 /> UNDERGROUND-MM10E S MATERIALS <br /> I . (;FNFRAL INSTRUCTIONS: <br /> w/ 1. Submit all information in triplicate. USE CARBONS. <br /> LwJ 2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the <br /> top of the page) location of nearby septic tanks, <br /> leachfields, bulgydings and underground public utility lines <br /> f (including water, sanitary sewer and storm sewer) . <br /> l� 3. Complete form "APPLICATION! FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> l� Complete the "Authorization to Release Analytical Data" form. <br /> Ld 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> U/6. Procedures should explain decontamination techniques if <br /> applicable, materials)aterias) utilized for rinsate, transportat on <br /> and/or storage of hazardous waste generated on site, andel <br /> specify the responsible party(ies) who will be disposin of <br /> J� waste generated on site. <br /> LJ y Procedures should explain purging and/or inerting method. <br /> 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 /> Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Tank Disposition Tracking Record". The holder <br /> of the rmit shall, be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> �1 . The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> l.l. Advance insDection notice of at least 48 hours is re uired b <br /> the an oa uin ocaT� i District. ro ria e advance <br /> e <br /> 11 cc ion no i la on i3f iuris ctional tire istrig >s <br /> contractor s responsibility. <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 W11- <br /> 468-3470 <br /> IC468-3470 460-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />