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ARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimento[.Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Jnyce,Sec'y. 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 /> ��_ r <br /> Daphne Shaw V . M k)'V ST H A f TT6CX City of Stockton <br /> Harvey Williams,Ph.D. I ' San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND 7MRAGE 5 �'I`6EFIN�-iTA'LATf6c50S MATERIALS <br /> I . ERAL INSTRUCTIONS: <br /> 1 Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> L3ipinq, streets and adjacent properties (north toward the <br /> top of the pagge) location of nearby septic tanks, <br /> e-achfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. Com tete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> /'Tank Program Fee Worksheet". <br /> --6-----Procedures should ex lain decontamination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> and/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 /> L� 7. Procedures should explain purging and/or inerting method. <br /> 0 8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> � r Routine Tank Removals" for sampling criteria. <br /> Complete the San Joaquin Local Ilealth District's SJLI-ID <br /> "Underground Tank Disposition Tracking Record". The holder <br /> the permit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <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 /> 0 11. Advance ins ct'ion notice of at least 48 hours is reguired_ b <br /> 1T7 San aJ aguin-LocaT ea UDYLr c ro ria -e -advance <br /> .ins c ion to iE�aFion o -jurisdictional iona irels -rict is <br /> con rac orT reSDonsi i i -v <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 <br /> 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 46.8-3280 <br /> AInF Inlnrmotinn ecu tw)n <br />