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9oAFID of TRUSTEES <br />AJ Crow, Pres. <br />V9,11 rimental, 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 wiMams, Ph,D. <br />q, <br />SAADJOAOUIN LOCAL HEALTH DIST ICT <br />SERVING <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOG! KHANNA. M.D., M.P.H., DISTRICT HEALTH OFFICER <br />1. • ..: �: •. i► �1R`IfC•:;i;[•i�iiV:41�� ��;8l�IH.I:trA::tt►,� � � : tt5; <br />I. GENERAL INSTRUCPIONS: - y <br />0-1. Submit all information in triplicate. USE C,ARBms . <br />Sen Joaquin County <br />City of Manteca <br />City of Ettcaion <br />City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />' I G ti F3 199 <br />2.f Include a detailed site map showing tank location and tyger'd Q <br />pipin , streets and adjacent properties (north toward the <br />]top <br />of lthe pagge location of nearby septic. tanks ENVIRONMENTAL HEALT <br />page <br />I id i ngs and underground public utility l iiVllrlSEi?VlCE H <br />= (including water, sanitary sewer and storm sewer). S <br />1K-) C.O a to .for "APPLICATION EOR PERMIT FOR UNDERGROUND TANK <br />"C.1-5 I <br />l <br />Complete the "Authorization to Re ase .Analy Lical Data" form. <br />�5. Subfi}it the ap cop a e�fee' a�� <br />Tank Program �ee orksheet". complete the "Underground <br />6. Procedures should explain decontamination techniques if <br />applicable, material{s) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />specify the <br />resptedonnssite <br />iblee,party(ies) who will be disposing of <br />waste <br />Procedures should explain purging and/or inerting method. <br />Describe in detail how soil and/or water samples beneath the <br />tanks invert will be obtained. Refer to "Samp9 lin Protocol <br />for Routine Tank Removals" for sampling criteria. <br />Complete the San Joaquin Local Health District's (SJL,HDJ <br />"[underground 'Tank Disposition Tracking Record". The holder <br />of the rmit shall be responsible for ensuring that this form <br />is comp teSl�s . '14 t r5cee <br />CCEOP'�0 kjIE.. M4 5* S1'�The x mum review t me for Clns is 15 working da <br />ys <br />from the date of receipt of the adequately completed Pian. <br />EH 23 040 <br />VISED 12/88 <br />7G'3 <br />-yo <br />Administration Clinical Services Environmental Health <br />468-34t)0 IBB -388 <br />468-3420 <br />Air Pollution Community services Laboratory <br />468-3470 4U-3= 460-3460 <br />Atf'>.c 1nlrWM*9k-.n Ago %WM <br />Public Health Nursing <br />A68 -38f30 <br />WIC <br />ABB -32'80 <br />