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BOARD OF TRUSTEES <br />Al Crow, Pres. <br />Earl Plmentel, Vice Pres. <br />Tommy Joyce, Sec'y. <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />• it a&Z 4 SIA,c-c f <br />SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />San Joaquin County <br />1601 East Hazelton Avenue City of Manteca <br />Stockton, California 95205 City of Escalon <br />City of Lodi <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />gl►���y GENERAL INSTRUCTIONS: <br />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 />(1 leachfields, page), <br />dings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />Complete form "APPLICA <br />CLOSURE". �. <br />TION FOR PERMIT FOR UNDERGROUND TANK <br />�a{y <br />Complete the "Authorization to Release Analytical Data" form. <br />DI 5. Submit the appropriate fees and complete the "Underground 5y,91 <br />Tank Program Fee Worksheet" <br />tZ <br />FePo DGS' / — us <br />U1�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 />Procedures should explain purging and/or inerting method. <br />C6 8 Describe in detail how soil and/or water samples beneath the <br />a,►(sN tank's invert will be obtained. Refer to "Sampling Protocol <br />or R ut'ne T nk movals" q� sin' lin crit r1 <br />Nl�c�c sc�scl> �/34 cK�g cri <br />Complete the San Joaquin Local Health District'P(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 />❑ 10. The maximum review time <br />from the date <br />for <br />Closure Plans is 15 working days <br />of receipt <br />❑ 11 Advance ins etion notice <br />L e an oaou1F oca <br />inspection notification <br />of <br />of <br />the adequately <br />at least 48 hours <br />completed Plan. <br />is re iced b <br />ea <br />District. <br />oproor>a e a vance <br />o <br />surf issdictional tiredi'striFf <br />is <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />460-3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3620 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />