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}' BOARD OF TRUSTEES <br />At Crow, Pres. <br />Earl Plmentel, Vice Pres. <br />Tommy Joyce, Secy. <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 />AtJOAQUIN LOCAL HEALTH DIAICT �� SERVING <br />San Joaquin County <br />1601 East Hazelton Avenue 1 / City of Manteca <br />Stockton, California 95205 ��"t City of Escalon <br />City of Lodi <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />City or Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />I. GENERAL INSTRUCTIONS: <br />❑ 1. S omit all information in triplicate. USE CARBONS. <br />❑ 2. I elude a detailed site map showing tank location and type, <br />p'pinq, streets and adjacent properties (north toward the <br />E p of the pa e.) location of nearby septic tankslEachfir <br />(including water, sani�ary sewer s and randund sttorrmblic sewerjllity lines <br />❑ 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />❑ 4.tbmit <br />plete the "Authorization to Release Analytical Data" form. <br />El 5. the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />❑ 6. Procedures should explain decontamination techniques if <br />a pplicable, materials) utilized for rinsate, transportation <br />atd/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 />❑ 7. 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 />for Routine Tank Removals" for sampling criteria. <br />❑ 9. Com <br />pete the San Joaquin Local Health District's (SJLHD) <br />" nderground Tank Dispositions racking Record" that holder <br />of the permit hall be 9 <br />i completed and returned the SJLHD. <br />❑ 10. The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />❑ 1.1. Advance inspection noticcof at least 48 hours is required by <br />EH 23E040 <br />REVIS D 12/88 <br />Aommistration <br />4G8-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />488-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />