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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> San Joaquin Count' <br /> At Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,Vice Pres City of Escalon <br /> Tommy Joyce.Secy. City California 95205 City of Lodi <br /> James F.Culbertson Cityof Tracy <br /> John D.Most M.D. JOG[ KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Ripon <br /> Virginia Mathews San Joaquin County <br /> Thomas Schubert,D.V.M. City of Stockton <br /> Daphne Shaw �1 �,�} �/ San Joaquin County <br /> Harvey Williams,Ph.D. /0�1 60. tJ /w �J <br /> APPLICATION FOR PERMI'P 6 CLOSE S TER T S <br /> UND <br /> GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> Include a detailed site map showing tank location and type, <br /> gipinc , streets and adjacent properties (north toward the <br /> op o the page) location of nearby septic tanks? <br /> leachfields, bulidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> t!d 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> 2/4. Complete the "Authorization to Release Analytical Data" form. <br /> E37 Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> V6/ Procedures should explain decontamination techniques if <br /> applicable, materials) utilized for rinsate' transportation <br /> and/or storage of hazardous waste generated on site, and <br /> V71specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> . Procedures should explain purging and/or inerting method. <br /> ❑ 8. Describe in detail how soil and/or water samplesbeneath the <br /> tank's invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> V9/ leteCompthe San Joaquin Local Health District' s (SJLHD) <br /> Underground 'lank Disposition Tracking Record". The holder <br /> of the permit shall. 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 Pian. <br /> ❑ 11. Advance insneection notice of at least 48 hours is reguired b <br /> e Sao Joaguin Local Health District. Al3progriate a vat <br /> Ins ec ion notification ot jurisdictionalireidistrictis <br /> Contractor's res onsibilTf <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Servicoa Environmental Health Public Health Nursing <br /> 468-3400 468-3030 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3824 408-3460 468-3280 <br /> AIDS Information 468-3820 - <br />