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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> W All Crow,Pres. SERVING <br /> Earl Plmente►,Vice P,es. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of EaCelon <br /> John D.Most M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert,D.V.M. Cly of nlpon <br /> Daphne Show <br /> Harvey Williams,Ph.D, Sen Joaquin CountyCity of Stockton <br /> UND� CR <br /> APPhTCATTON ICOR P TI2MTT TO (x,OSr San Joaquin County <br /> S MATERIALS <br /> I. GENERAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARDONS, <br /> 2. Include a detailed site map showing tank location and t <br /> voe <br /> piping, streets and ad 'acent properties (north toward t e <br /> toy o the page) location of nearby septic tanks, <br /> leachfields, buiidlrn)s and underground public utility lines <br /> (including water, sanitary sewer and storm sewer) . <br /> . <br /> 3. Compplete form "APPLICATION FOR PERMIT FOR UNDERGROUND TAMC <br /> CLO 5URE It. <br /> 4. Complete the "Authorization to Release Analytical Data" form. <br /> 5. Submit the appropriate fees and complete the "Underground <br /> R Tank Program Pee Worksheet". <br /> 1J � 6. Procedures should explain decontamination techniques if <br /> V`� applicable, inaterial(s) utilized for rinsate, transportation <br /> and/or storage of lu zardous waste generated on site, and <br /> (�1 specify the responsible party(ies) who will be disposing of <br /> waste generated on site. <br /> 3 7. Procedures should explain Purging ani <br /> 9 g c/or inerting method. <br /> 8. Describe in detail how soil and/or water samples beneath the <br /> forko invert will be obtained. Refer to "Sampling Protocol <br /> for Routine Tank Removals" <br /> for sampling criteria. <br /> 9. Compplete the San Joaquin Local Health District's (SJLHD <br /> Ts,"Underground 'Tank Disposition Tracking Record". The holder <br /> 1L the permit shat]. h'� r.e,` Onsihle for eruuring that this form <br /> completed and returned Lhe SJLHD. <br /> 10. The maximum review time for Closure Plans <br /> from the date of receipt of the adequatylcompletedip ?adays <br /> an. <br /> IBJ 11. dvance 'ns. ction notice of. at least 48 hours is re u.�-' �n,_a�ctu�n oc;1-TTcaIt _T_ <br /> ins c ton notallral�on ur ,Tcrliona ire rc7'a�;a�� �ce <br /> c'ot� r��c _oC 5 res �onsiU-iTi C <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services <br /> 460.0400 4E8-3000 Envlronmen!al Hortlth Public Heal!h Nursing <br /> 468.3420 <br /> Air Pollution460.0960 <br /> 468.0470 <br /> Community Services Laboratory 460.3820 W►,,., <br /> 400-3460 <br /> �Fn.�7Gn <br />