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�D OF TRUSTEES �.►N JOAQUIN LOCAL HEALTH D15TRIC - SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue p qCity of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 ..t City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast, M.D. JOG, 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 /> 11NDERGROUN5-S" � TWK.i—.'3'�MRTN(-,-14AVT2=S MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> 2/11, <br /> Submit all information in triplicate. USE CARBONS. <br /> Q12. Include a detailed site map showing tank location and type, <br /> LL�ipinq, streets and adjacent properties (north toward the <br /> top of the page) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lin s <br /> ( including water, sanitary sewer and storm sewer) . + Vel I0C-CJ-o n 5 <br /> ❑ 3. Com Tete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLO URE". <br /> Nva 44 Complete the "Authorization to Release Analytical Data" form. <br /> ASS 5. Submit the appropriate fees and complete the "Underground <br /> 'Tank Program Fee Worksheet". <br /> -jC-�-p6. Procedures should explain decontamination techniques if <br /> C o � appplicable, material(s) utilized for rinsate, transportation <br /> at�d/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 /> CO� 7. Procedures should explain purging and/or inert:ing method. <br /> �f/A8 . Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> �cc for Routine Tank Removals" for sampling criteria. <br /> 9 .r Complete the San Joaquin Local Health District's (SJL}ID) <br /> Cin "Underground Tank Disposition Tracking Record" . The holder <br /> of the permit shall be responsible for ensur ng th�}t this fp`mn 0+ <br /> �� is completed and returned the SJLHD. C Only. ctCCotj4 - `-� rl�► T <br /> Ltd 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Pian. <br /> . Advance ins coon notice of at least 98 hours is re uired b <br /> Grc e ar oa u>n oca ea >s ric ro ria e ,a vanct� <br /> Co n1 f ins coon no i ica ion o " ur is lc Lona iredist r is - s <br /> 5��- of -� l mf"con rac or s respons> > i "y• / �h��r1 F Q , ICQ�roV o� C �oS��'L-in-�ac� <br /> EH 23 040 l <br /> ^r REVISED 12/88 Under � e- <br /> I v 5o ; l bo r I ►'t 5 u-'l � � V1o� fit. <br /> 1� Doo CA L U r� I i a �P � n afi'�n on s i f� c,�h�� c h was <br /> CI o c v 61 e,�t�-e.� 5�j � C o,�-{- , <br /> 1 WCLS <br /> 1 d,;s c o V��'��-- J� ,�L / <br /> DVP c�� I I -�o/-Mc.l` ! �l �o C.Cc:f r o►� 5 Sha �� - aCZC��Sseof <br /> � �►'` - Pte,--�rr►�P_c;L , <br /> + eq v � ' CsS -5tt , e1 ri s nen 15 <br /> Public Health Nursing <br /> Administration Clinical Services Environmental Health <br /> 468-3400 468-3830 468-3420 468-3860 <br /> w Community Services laboratory WIC <br /> Air Pollution ty 468-3280 <br /> _ V 468-3470 468-3820 468-3460 <br /> \M, AIDS Information 468-3820 <br />