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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> San Joaquin County <br /> Al Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,Vice Pres. City of Escalon <br /> Tommy Joyce,Secy. Stockton,California 95205 <br /> City of Lodi <br /> James F.CulbertsonCity of Trac <br /> John D.Mast,M.D. JOGI 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 San Joaquin County <br /> Harvey Williams,PhO <br /> APPLICATION FOR PERMIT TO CASE <br /> UNDERGROUN�'1`APK�u'[4)[FIP�)T�LT+-1-S MATERIALS <br /> �//I GENERAL INSTRUCTIONS: <br /> L✓1 .Y. Submit all information in triplicate. USE CARBONS. <br /> [/g/2. Includea detailed site map showing tank location and type, <br /> piping, streets aril adjacent properties (north toward the <br /> Min <br /> of <br /> thee) location of nearby septic tanks, <br /> leachfields, buildings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> � CLOSURE". <br /> V¢! Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the apppropriate fees aril cofpplet-e the "Underground <br /> 'Tank Program Fee Worksheet". <br /> (3/6. 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 /> ;)8* <br /> I Procedures should explain purging and/or inerting method. <br /> 8. Describe in detail how soil and/or water samples beneath the <br /> tank's invert- will be obtained. Refer to "Sampling Protocol <br /> C'1/ for Routine Tank Removals" for sampling criteria. <br /> 9. Complete the San Joaquin Local Health District's (SJLHD) <br /> "Underground 'Tank Disposition Tracking Record". The holder <br /> of thepermit shall be responsible for ensuring that this form <br /> is completed and returned the SJLHD. qq <br /> days <br /> 10 fromThe Bthemum dateeoferecetiptfor of thesure Plans adequatelyiworking <br /> it/il. Advance ins ection notice of at least 48 hours is re uired by <br /> e an oa uin oca ea is ric ro ria e a vane <br /> IE <br /> c ion notification o ' uris is lona ire is ric i.s <br /> con rac or s responsi i i y. <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 <br /> 466-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />