Laserfiche WebLink
BOARD OF TRUSTEES SAOAQUIN LOCAL HEALTH DISTIOT San JoaquinSERVING <br /> AI Crow,Pres. 1601 East Hazelton Avenue City of Manteca <br /> Earl Pimentel,Vice Pres. Ci of Escalon <br /> 6 Tommy Joyce,sec'y. Stockton, California 95205 City <br /> City of Lodi <br /> _ James F.Culbertson Ci of Trac <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER ry <br /> 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,Ph.D. <br /> APPLICATION FOR PERMIT TO Cf,OST _ <br /> UNDERGROUND STORAGE TANKS STORING HA7.ARDOIJS MATERIALS <br /> GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS. <br /> L� 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, buildings, and underground public utility line--- <br /> ( including <br /> ines( including water, sanitary sewer and storm sewer ) . <br /> 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> 1 CLOSURE". <br /> L'1 4. Complete the "Authorization to Release Analytical Data" form. <br /> [� 5. Submit the appropriate fees and complete the "Underground <br /> Tank Program Fee Worksheet". $ 10 t' <br /> G. Procedures should explain decontamination techiriques if <br /> applicable, material(s) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on siLe, and <br /> specify the responsible party(ies) who will be disposing of <br /> wa=ge generated on site. a i ' � <br /> ❑ 7. Describe in detail how soil and/or water samples beneath the <br /> tank's invert will be obtained. Refer to "Sranlpling Protocol <br /> for Routine Tank Removals" for sampling criteria. <br /> 8. Complete the Sari Joaquin Local Health District:'; (SJLHD) <br /> "Underground Tank Disposition Tracking 'record". The holder <br /> of the perraiL Shall be responsibi for ensuring that thii: form <br /> _ted a to i i he <br /> i5 completed and rc�.uY.ireC+ + <br /> ❑ 9. Advance inspection notice of at least 48 )tours is rL aired by <br /> the San Joaquin Luca] Health D15tfA_ ALpropri_ate_advance <br /> inspection notification of iurisdiCl10nal firr: district i:: <br /> contractor 's resr)0n•cibility. <br /> l�lrri. Mt 'Hol) ok i'ua-Crn,(. � nt.K <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Healtfr Public Health Nursing <br /> 468-3400 468-3830 468-3420 468.3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 469-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />