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Now tc,—r4 <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT //l SERVING <br /> At Crow,Proo 0 San Joaquin County <br /> Earl Pimento],Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 Cly of Eacalon <br /> James F.Culbertson Cly of Lodi <br /> John D.Mast M.D. JOGI KHANNA, M.D., M.P.H.. DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews city of Ripon <br /> Thomas Schubert D.V,M. San Joaquin count' <br /> Daphne Shaw Cly of Stockton <br /> Haney Williams,Ph.D. San Joaquin county <br /> APPI.ICATION FOR PERMIT CI nSF <br /> UUNDrRGROUND STORAGE TANKS STORING HAZ&EDOUS MATER18LS <br /> Jl� GR'fETtAL INSTRUCTIONS: <br /> I.. Submit all information in triplicate. USE CARBONS. <br /> Q 2. Include a detailed site map showing tank location and type, <br /> piping, streets ano ao)acent propertlea (IwLUj Luwat:d the <br /> top of the page), location of nearby septic tanks, <br /> leachfields, buildings, and underground public utility lines <br /> ��( including water, sanitary sewer and storm sewer) . <br /> l, 3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br /> CLOSURE". <br /> C3/4. Complete the "Authorization to Release Analytical Data" form. <br /> [D//5, Submit the appropriate fees and complete the "Underground <br /> / Tank Program Fee Worksheet". <br /> E_ G. Procedures should explain decontamination techniques if <br /> applicable, material(,,) utilized for rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the responsibld party( ies) who will be disposing of: <br /> waste generated on site . <br /> b//7, 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 /> hY 8. 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 returne(I the SJLHD. 1. <br /> L� 9 . kilvance irizycetLpn notice Qf gt lea t 48 1 ours i' rerqaired by <br /> the Can Joagui.lLLtx'ral Ids:+a+ tJ h D�st�iGt_ bDXg tlLdtr ar]vance <br /> insr&ction notification of�1t_ rz i,d'icti- ia] fire jiitr_i_ct is <br /> contractor 'sresponsibility. <br /> ID. 1✓4t=tb�,a¢5 �4kta ldj �OR�:fAJ1C,- <br /> FH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 486-3400 488.3830 468.3420 489.3800 <br /> Air Pollution community Services laboratory WIC <br /> 460.3470 468.3820 488.3460 488.3290 <br /> AIDS Information 48R-94Fn <br />