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U <br />SAARO OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />San Joaquin County <br />Al Crow, Pro& <br />1601 East Hazelton Avenue <br />city of Manteca <br />Earl Pimentel, Vice Pres. <br />Stockton, California 95205 <br />City of Escalon <br />Tommy Joyce, Secy. <br />City of Lodi <br />James F. CulbertsonCity <br />John D. Meet M.D. <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />of Trac <br />City of Ripon <br />Virginia Mathews <br />San Joaquin County <br />Thomas Schubert D.V.M. <br />City of Stockton <br />Daphne Shaw <br />San Joaquin County <br />Harvey Williams, PhO. <br />GENERAL INSTRUCTIONS; <br />U✓ . Submit all information in triplicate. USE CARBONS. <br />li 2* Include a detailed site map showing tank location and type, <br />piping, streets and adjacent properties (north toward the <br />top of thepagej location of nearby septic tanks, <br />leachfields, bu?.idin(js and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />Q 3 Coleete form "LIC6TION PERMIT FOR UNDERGROUND TANK <br />E� <br />Complete the "Authorization to Rele� pnalAiW Data" form. <br />❑ 5. Submit the appropriate fees and c-. a these "Underground <br />Tank Program Fee Worksheet". <br />(t,lU 6.) Procedures should explain decontamination techniques if <br />("lL� applicable, materially) utilized for rinsate, transportation <br />an storage of hazardous waste generated on site, and <br />specify the responsible party(ies) who will be disposing of <br />frwaste generated on site. <br />�D 7 Procedures should explain purging and/or inerting method. <br />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 />Complete the San Joaquin Local Health District's (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 for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />EH 23 090 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />466-3470 <br />Clinical Services <br />468-3030 <br />Community Services <br />460.3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3820 <br />Laboratory <br />466-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468.3280 <br />