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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br />At Crow, Prea. <br />Earl Plmentel, vice Pres. 1601 East Hazelton Avenue <br />Tommy Joyce, Sec'y. Stockton, California 95205 <br />James F. Culbertson <br />John 0. Most M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Hervey Williams, Ph.D. <br />GENERAL INSTRUCTIONS: <br />ie Submit all information in triplicate. USE CARBONS. <br />Lu 2. Include a detailed site map showing tank location and type, <br />piping, streets and adjacent properties (north toward the <br />top of the page)location of nearby septic tanks, <br />leachfields, but dings and underground public utility lines <br />_/ (including water, sanitary sewer and storm sewer). <br />Ql 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />—/ CLOSURE" . <br />VId y. Complete the "Authorization to Release Analytical Data" form. <br />5Submit the appropriate fees and complete the "Underground <br />�7Tank Program Fee Worksheet". <br />6. Procedures should explain decontamination techniques if <br />applicable, material(s) utilized for rinsate, transportation <br />at 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 />C�l/ �7. Procedures should explain purging and/or inerting method. <br />[1/8. 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 />SERVING <br />San Joaquin County <br />City of Manteca <br />Cly of Escalon <br />Cly of Lodi <br />City of Tracy <br />Cly of Ripon <br />Sen Joaquin County <br />City of Stockton <br />San Joaquin County <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 />is completed and returned the SJLHD. <br />t✓ -0. The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />Q�11. Advance inspection notice oofat least 48 hours is required by <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468.3400 <br />Air Pollution <br />468-3470 <br />Clinical Servlcos <br />468-3030 <br />Community Services <br />460-3820 <br />Environmental Health <br />468.3420 <br />Laboratory <br />408-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468.3280 <br />