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DOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow.Pre&. San Joaquin rounr+ <br /> Eerl Pimentet,vice Pfes. 1601 East Hazelton Avenue City of Maniacs <br /> Tommy Joyce,Secy. Stockton,California 05205 Cory of Escalon <br /> 4` \ Jamet F.Culbertson City of Loin <br /> John D-Most,M D JOGI KHANNA, WD., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews Cory of nipon" <br /> Thomas Sahubart,D.V.M. San Joaquin County <br /> Daphne Shaw City of 5focklon <br /> Harvey Williams.PRD. San Joaquin County <br /> APPLICATINJ FOR PERMIT TO CLOSE <br /> IJtJD 2CJ�GUN��'h�F� �f�FJn�`"�'ll'SfZ7S S MAIFPT&LS <br /> 1. GF. IZAL I NSTRII.=IONS: <br /> L1� 1. Submit all information in triplicate, USE CARBONS. <br /> 2. Include a detailed site gap showing tank location and type, <br /> iping, streets and aaiaL:ent properties (north toward the <br /> op o¢ the page location of nearby septic tanks, <br /> leachfields, u dings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer). <br /> f�/3. Cooplleette.form "APPLICATION FOR' <br /> FiMMIT FOR UNDERGROUND TANK <br /> 1/14. Complete the "Authorization to Release Analytical Data" form. <br /> L1 5. Submit the appropriate fees an6 -omplete the "Underground <br /> ` Tank Program Fee worksheet''. <br /> d 6.. Procedures should explain decon`zarnination techniques if <br /> applicable, materials) utilized for rinsate, transportation <br /> and/or storage of hazardous wa$Ve generated on site, and <br /> specify the reLponsible party(ies) who will be disposing of <br /> ` waste generated on site. <br /> dd7'. Procedures should explain purging and/or inerting method. <br /> L9 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 /> Lig 9. Compplete the San Joaquin Local Health District's (SJLHD) <br /> "Underground Tank Disposition Tracking Record" The holder <br /> of thepermit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. <br /> l:! 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 Insvection notice of at least 48 hours is re-uired b <br /> Me san oa ulnocaHealthis roc ro ria a a�vanc? <br /> ins _ci :s icriona ire district is <br /> con rac or s response t i y, <br /> i:H 23 040 <br /> REVISED 12/88 <br /> Administration Ctinical services EnviMnmental Heallri Public Health Nursing <br /> 468.340o 468.3330 468.3420 468-3960 <br /> Air Pollution Community Services Laboratory WIC <br /> 468.3470 4615.3820 488.3460 468-3280 <br /> AIDS lniormat on 466.3o2o <br />