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BOARD of TRUSTEES `-dAN JOAOUIN LOCAL HEALTH bvSTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Plmantal,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Selly. 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 /> L�NDFRGRO[�N S MATERIALS <br /> lld' I. GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS. <br /> �\ 2. Include a detailed site map showing tank location and type, <br /> 1� ipinqg, streets and adjacent properties (north toward the <br /> top of s,the pa a) location of nearby septic tanks, <br /> leachfieldBuildings and underground public utility lines <br /> R Z (including water, sanitary sewer and storm sewer) . <br /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 5. Miltza?e "A thori tion to Release Analytical Data" form. <br /> the approp ate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 2. 6. Procedures should a lain decontamination techniques if <br /> applicable, materiallys) 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 /> �' 7 Procedures should explain purging and/or inerting method. <br /> 'S- 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 /> I <br /> 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 /> Ais 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 Pian. <br /> ❑ . Advance insDection notice of at least 48 hours is re iced b <br /> e San oa in Local Healthis ric ro ris e a vance <br /> 1-n-sWction nes i tics ion of juriScIiCtlonaiire district is— <br /> contrarForls responsibility. <br /> RREEVISED23 42/88 <br /> Administration Clinical Services Environmental Heafth Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS fnformalion 468-3820 <br />