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r SERVING <br /> _!I_ �.a <br /> SAN AQUIN LOCAL HEALTH DISTR! <br /> San Joaquin <br /> BOARD of TRUSTEES City of ManleCe <br /> Al Crow,Pres. 1601 East Hazelton Avenue City of EWWOn <br /> Earl Pimentel,viae Pres. Stockton,Call1ornia 95205 City of Lodi <br /> Tommy Joyce,soey. City of Tracy <br /> James F.Culbertson JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER R City 01 Ripon <br /> John 0.Mast.M.D. ... San Joaquin County <br /> virglnla Mathews City of Stockton <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw <br /> Harvey Wtlilams,Ph.D. /APPLICATION FOR pERMI'I CLOSE <br /> MWAI, INSTRUCTIONS: - <br /> 1, submit all information in triplicate. USE CAEtBOMS. <br /> �. Include eet �nscenroeeskrtont ' <br /> p1C ' stresadajacetpprti (north- toward the <br /> o0the <br /> page) location of nearby septic tanks <br /> le chElelds, Fiuifdings and underground public. utility lines <br /> (including water, sanitarY sewer and :storm sewer) . <br /> UNDERGROUND T <br /> 3. complete form ,AppLICATION FOR PERMIT FOR <br /> cL05URE . . <br /> 4. Complete the "Authorization to Release Analytical Data" form, <br /> per, Submit the appropriate fees and completerthe "Underground <br /> Tank Program Fee Worksheet". <br /> W/6/. " Procedures -should al s)ln decantized fonatinsaitechnrquepartatian <br /> es If <br /> ap licable, maters <br /> at /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 /> ❑ B. Describe In detail how soil and/or water samples beneath the <br /> forkRoutinerTanklRbe emmovabls" for sampling criterPia. Protocol <br /> Complete the San Joaquin Local Health District's (SJLHD/9. i <br /> Underground 'Tank Disposition Tracking Record". The holder <br /> of the Permit shal]. 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 inspgction notice of at least 48 hours is reggired b <br /> A ,he Sa Joaguin Loqealt1i DIsUr-REE, Appr9priate advance <br /> ins ec ion not Tca�ion o u ac is i e d-_fri his <br /> Coli rac az „s,,_ eSpg gilbility. <br /> EH 23 040 <br /> �i REVISED 12/68 <br /> Of :.. . <br /> Il , <br /> Sl <br /> Ti <br /> } <br /> .. w <br /> Sha . <br /> Of Administration Clinical Services Environmental Health Public Health Nursing <br /> tit 468-3400 <br /> 469-3030 468.3420 468-3960 . <br /> Slit Air Pollution Community Services Laboratory WIC <br /> 468.3470 460.3820 468.3460 468-3280 <br /> r_ <br /> AIDS Information 469-302'1 <br />