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0 <br /> -BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimental,vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. <br /> Daphne Shaw San Joaquin County <br /> HanCity of Stocktoney Williams,Ph.D. San Joaquin County <br /> IJNDERCROUN�P115 31�(FATG <br /> APPLICATION TO <br /> MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> L1 1. Submit all information in triplicate. USE CARBONS. <br /> 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, buiidings and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> YJ3. CLS ,,. <br /> form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> /4. Complete the "Authorization to Release Analytical Data" form. <br /> q' 5. Submit the appropriate fees and complete the "Underground <br /> 'Tank Program F'ee Worksheet-". <br /> E�6. 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 /> specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> 11�/7. Procedures should explain purging and/or inerting method. <br /> YJ 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 /> 1�r/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. <br /> 1�10. The maximum review time for Closure Plans is 15 working days <br /> from the date of receipt of the adequately completed Plan. <br /> 1. Advance ins -cti0n notice of at least 98 hours is re uired by <br /> t e an <br /> Joaquin oca ea t Ls rLc r0 ria e advance <br /> ins c ion no mica ion cfuras >c iona ire is tic - is <br /> contractor's resDonsibi 1 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 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />