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BOARM" OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DI TRICT "MNG <br /> ,J Crow,Praa San Joaquin County <br /> Earl Plmantel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Fxalon <br /> Jam*&F.Culbertson City of Lodi <br /> John D.Most.M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thom"Schubert D.V.M. t City of Ripon <br /> Daphne Shaw - v 1_L-. I. P.�^�-t.-, Sen Joaquin County <br /> City of woken <br /> Harvey Wd"ma,Ph.D. <br /> San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE UNDERGROUND S MATERIALS <br /> � <br /> I GENERAL INSTRUCTIONS: <br /> 0 1 Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, <br /> Min streets and adjacent properties (north toward the <br /> top of the pa e) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3. /CompUREtt form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> 2-/ 'CC <br /> ompASlete the "Authorization to Release Analytical Data" form. <br /> .5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> U' 6. Procedures should explain decontamination techniques if <br /> ap licable, materials) utilized for rinsate, transportation <br /> a�/or storage of hazardous waste generated on site, and <br /> waste g the responsible party(ies) who will be disposing of <br /> .,specify <br /> generated on site. <br /> 7./Isrocei:es 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 'rank Removals" for sampling criteria. <br /> Ld 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 /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> ❑ 11. Advance ins2tctig notice of gt least 18 our is r ulna b <br /> e oa utn oca ea �s ric oproarta e a vane <br /> insptction notification ol jurisdictionalire dt5trct is <br /> contractor's 1 1 <br /> EH 23 090 <br /> REVISED 12/88 <br /> PAYMENT <br /> RECEIVED <br /> JUL - ' 19 ; <br /> ENVIRONMENTAL HE.ALT- <br /> I'-``.".'AIT.ISERVICES <br /> Adminuvabon Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 465-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468.3470 468-3820 468-3460 468-3260 <br />