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0-- <br /> kC /�f <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Plmentel,Vlce Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy Stockton,California 95205 city of Escaton <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 S ELTERIALS <br /> GENERAL INSTRUCTIONS <br /> ,3/1. Submit all information in triplicate. USE CARBONS. <br /> 2 2, Include a detailed site map showing tank location and type, <br /> ipinc , streets and adJacent properties (north toward the <br /> op o the page location of nearby septic tankst <br /> leachfields, bulgydings and underground public utility lines <br /> ts000g&lw r- -P) -f eo-•c.�a i arm y sewer and storm sewer) . <br /> Ll 3. CompQlete form ""APPLICATIMI FOR PERMIT FOR UNDERGROUND TANK <br /> — / CL05URE". <br /> M 4. Complete the "Authorization to Release Analytical Data" form. <br /> 9.5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> Procedures should a Iain decontamination techniques if <br /> ap licable, materialgs) utilized for rinsate, transportation <br /> a /or storage of hazardous waste generated on site, and <br /> specify the reLponsible party(les) who will be disposing of <br /> �,� waste generated on site. <br /> t2 7 Procedures should eAplain purging and/or inerting method. <br /> ( 8. 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 (SJLIfD) <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. 7 tJkZ totA-- Veu f <br /> ❑ 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Pian. <br /> ❑ 11. Advance insDection notice of at least 48 hours is re iced b <br /> ' e gan Joaduln Local-Fe—alth DistrictLocal—Fe—aro rra e advance <br /> ins ec ion notification ot lurisdictionalireisd trict is <br /> contractor—Is response i Yy_ <br /> EH 23 040 <br /> REVISED 12/88 <br /> Admirllstrallon Clinical Services Environmental Health Public Heallh Nursing <br /> 468-3400 468-J830 463-3420 468-380 <br /> Air Potlutlon Community Services Laboratory WIC <br /> 468-3470 468-3820 460-3460 468-3250 <br />