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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Plmentel,Vice Pres. 1601 East Hazelton Avenue City o1 Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast M.D. JODI KHANNA, M.D„ M.F.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. San Joaquin County <br /> Daphne Show City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> W,PLIC'.ATION FOR PERMIT TO 171,17Isr <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERI,8 S <br /> GENERAL INSTRUCTIONS: <br /> 1� Submit all information in triplicate. USE CARBONS. <br /> 2. Include a detailed site map showing tank location and type, <br /> piping, streets arta au3acent properLlea (nucLlt Luwava the <br /> top of the page) , location of nearby septic tanks, <br /> leachfields, buildings, and underground public utility lines <br /> ( including water, sanitary sewer and storm sewer) . <br /> Lf 3, Complete form "APPLICATION FOR PMMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> `Y/ 4 Complete the "Authorization to Release Analytical Data" form. <br /> Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". <br /> 6. 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 responsibld party( ies) who will be disposing at <br /> �// waste generated on site . <br /> t✓J 7, Describe in detail how soil and/or water samples bcneath the <br /> tank's invert will be obtained, Refer to "Sampling Protocol <br /> / for Routine Tank Removals" for sampling criteria, <br /> $ 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 Lhat this form <br /> is completed and returneQ the SJLHD. 1. <br /> 9 Advance in^oectl,Qn notice of at least 49 (Lours i'- rF_ , auirPd by <br /> jthe Can Joacjiairi LciC'ral i(otf tl h D.istrigt _ n IZid r advance <br /> insre,Gtion not ific tion at juri;d'ictioial fire district, is <br /> contractor 's responsibility. <br /> FH 23 040 <br /> RAISED 12/88 <br /> Aoministretlon Clinical Services Environmental Health Public Health Nursing <br /> 468.3400 488•3830 468.3420 468-be80 <br /> Air Pollution Community Services Laboratory Wic <br /> 466.5170 468.5820 488.3460 468.3260 <br /> AIDS information 4RR-147n <br />