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BOARD OF TRUSTEES <br />Al Crow, Pros. <br />Earl Pimentel, 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 Williams, Ph.D. <br />• <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />L1111 � 111 XITI &1k Oft .4 1 ilk Iasi W40 0 10-7011140; <br />I. GENERAL INSTRUCTIONS: <br />Submit all information in triplicate. USE CARBONS. <br />2 Include a detailed site map showing tank location and type, <br />piping, streets and adjacent properties (north toward the <br />top of the page) location of nearby septic tanks, <br />leachfields, bbuiidings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". Nwd a 7" PIA `� <br />ll�f' 4 Complete the "Authorization to Release Analytical Data" form. <br />l9' 5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />Lvl 6. Procedures should explain decontamination techniques if <br />applicable, material(ls) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />/specify the responsible party(ies) who will be disposing of <br />waste generated on site. <br />7- Procedures should explain purging and/or inerting method. <br />a-8. Describe in detail how soil and/or water samples beneath the <br />tank's invert will be obtained. Refer to <br />if Protocol <br />forR t' T' L. l"f <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <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 />ou ine an emova s or sampling criteria. <br />El 9. omplete the San Joaquin Local Health District's (SJLHD) <br />'Underground `Tank Disposition Tracking Record". The holder <br />of- the permit shall. be resonsible for ensurin that this form <br />is completed and returned the SJLHD. TO Tr , �p OnSIfe ? <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 />❑ 11. Advance ins fiction notice of at least 48 hours is recruired b <br />E -Fie an , oa uin soca . Iie'a iDistrict-7-9p-pro rr.a e advance <br />.ins�c ion no i ica ion o aurisr_ iiona ire id'�ic�-is <br />con rt actor s' resp`on�iTity. <br />EH 23 040 <br />REVISED 12/88 <br />Administration Clinical Services Environmental Health <br />468-3400 468-3830 468-3420 <br />Air Pollution Community Services Laboratory <br />468-3470 468-3820 468-3460 <br />',InS 9n4m,rnr nR6n,n AAA.IAW <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />