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r� <br /> BOARD OF TnusTEES ON JOAQUIN LOCAL HEALTH DM mICT SERVING <br /> Al Crow,Pros. <br /> an Jonquln County <br /> r-nrl Pimnnlel,Vico Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyca,snc,y. Stockton, California 95205 <br /> Jmmns F.CtUlbnrt�+on City of ECly of Lodi Lodi <br /> John D.Mnsl,M.D. JOGI KIiAIJNA, M.D., M.P.H., DISTRICT HEALTH orricEn City of Tracy <br /> Vlrpinln Mnthnws City of Ripon <br /> Thomns Schubert,D.V.M. San Joaquin County <br /> Dnplrnn Shnw City of Slocklon <br /> Harvey wlllinm:q.Ph.o. San Joaquin County <br /> AI'I?t_Ir,A,rTON FOR PERMIT TO MOS <br /> UNDERGROUND MRAGE TANKS STORING 11A7.ARDOUS MATERIALS <br /> GENERAL INSTRUcr1oNS: <br /> , i <br /> 1. ul7mit all information in triplicate. USE CARBONS. <br /> 2. I1)l7111rle ra detailrd site m.-ap showing tank locnLiun and 1'Y4x-, ' FH <br /> Vipi.irrj, streeLs and adl.-acent pro[>nr-tles (north toward the � lS�11V'vc� <br /> 1:011 of t:11r_ paq(!), locaLion of nearby i.(-pL1c tank�;, <br /> lelacll£•ields, buildings, and and(argrourlrl [sul}l.ic utility lines <br /> including water., sanitary sewer and storm sewer) . <br /> 3, mplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TA14K <br /> CLOSURE". <br /> 4. ompl.eLe Lire "Aut:}rorization to Release Analytical DaLa"' form. <br /> £i. Sut� t <br /> -hr rapi,ro[ar i�it:p fees and complete the "Underground <br /> tik Proyrain Fee Worksheet". <br /> I?ror-r+dl.ares should explain clecontarnii"aLioil t:pchnicltiles iF <br /> a[�i,l.ictrt�lp, rTMateriral(s) utilized for rinsate, transport:1LIon <br /> and/or storage of hazardous waste gi-?nerated on site, atad <br /> IC-ify the responsibld party(les) who will be disposing oL- <br /> waste genera Led on site, <br /> 7. in detAll )low soil and/or water sampler ix-,neaL}a the <br /> 's invert will. ty-- obtained. Refer to "S,_impling protocol <br /> for outlne "rank Removals" for sampling criLeria. <br /> 8. Co . leL-e the San Joaquin Local 11p lLh Distr icl•'ra t.„JLIIi)) <br /> ” nelcrground Tank Disposiklon Trtac�klrag Record'". Tho hn]cter <br /> o[: the permit shall, be responsible for ensuring that L-his form <br /> Is completed and returned Lhe SJL11D. <br /> 9. 1ldvance inspection notice of at least A[] hours i;; 1Cpgrairecl try <br /> tlrr San 1iLOt_. 1 ltrtalttt Dirtzic,k.�71I;plrcrfrri�7L aclv.a.nce <br /> Inspection notification nC�url'a+lir_l conal t rp rlistr[r.t is <br /> coraLractox 's res on,ibility. <br /> rv. i-(or.+.a K -1-A Jk <br /> [It 23 040 <br /> REVISED 12/88 <br /> Adm inkir nlion Cllnicnl Sorvlces Environrnentnl iieailh r ub1c Ilnnith Nureing <br /> 46n-3400 488-3830 468-3420 489-3860 <br /> Air rowlion Community Snrvlces Labnrnlory wic <br /> 468-3410 468-3820 468-3460 488-3280 <br /> AIDS Information 4fin-wri <br />