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SAN JOAQUIN COUNTY <br /> BOARD OF TRU8TEE8 PUBLIC HEALTH SERVICES r SERvin <br /> AI Crow,Prea. ENVIRONMENTAL HEALTH DIVISION <br /> Earl Pimentel,vice Pr s, p,0. BOX 2009 G San quin Cow <br /> Tommy Joyce,Secy, fj ( City of Mani*, <br /> James F.Culbertson STOCKTONr CA 95201 City of Escair <br /> JOhn D.Mast M.O. JOOI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER CIN of Lo <br /> Virginia Mathews CIN Of Tra, <br /> Thomas Schubert,D.V.M. City of nipc <br /> i Daphne Shaw San Joaquin Coun <br /> Harvey Williams, Ph.D. City of SIOOktc <br /> San Joaquln Coup <br /> APPLICATION IOR PERMIT To MOSE <br /> 02ERGROIMD�"T2�RAOE. '�Iq5 S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> Submit all information in triplicate. USE CARBONS, <br /> LIQ T. Include a detailed site map showing tank location and type <br /> pspiny, streets and adjacent properties (north toward the r <br /> Min <br /> of the pagbe) location of nearby septic tanks <br /> leachfields, uiiidirnJs and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> 3, CooplleeEte form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> ( ee Com letg. the "Authorizat on to Relea Analytical Data" form. <br /> cu i c �<�ts `it m <br /> a <br /> f�5. Submit the a�prop r ate ees ac <br /> 2-5. com Tete the "Underground <br /> ©6Tank Program Pee Worksheet ". <br /> . Procedures should explain decontamination techniques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the reWonsible party( ies) who will be disposing of <br /> waste generated on site. <br /> �7. Procedures should explain purging and/or inerting method. <br /> (0"8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to 11 Sampling Protocol <br /> for Routine Tank Removals" for sa,upling criteria. <br /> 0-9. Complete the San Joaquin Local Health District's (SJLHD) <br /> of thegpreoXmltlshallibeore�li�onsihlekfor ensuring that thise rm <br /> iS completed slid returned Lhe S7LHD.' <br /> O 10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> Q ll. Adv ce ect nn-a a of a-�1 t 1 � t�grs re ul�ed by <br /> 1 a `sea c rn r>a e advance <br /> fns <br /> ti on np i�7 1or o u 5 i na re i 1c is <br /> con rac r es o >, <br /> EH 23 040 <br /> REVISED 12/88 <br /> Admwistratlon Clinical servicos Environmental Health <br /> 468.3400 468.3030 468.3420 Publk' Health Nursing <br /> 468.3860 <br /> Air Poilueon Community Services Leooratory <br /> 40.3470 468.3820 WIC <br />