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BOARD OF TRUSTEES <br />Al Crow. Pres. <br />Earl Pimentel, Vice Pres. <br />Tommy Joyce, Secy. <br />James F. Culbertson <br />John D. Most, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />*V '44-rH VX <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />JOGI KHANNA, M.Q., M.P,H., DISTRICT HEALTH OFFICER <br />CAT <br />I GENERAL INSTRUCTIONS: <br />Submit all information in triplicate. USE CARBONS. <br />Q/2. Include a detailed site map showing tank location and type, <br />ipinc, streets and adjacent properties (north toward the <br />op o the page) location of nearby septic tanks, <br />aeachfields, 5uiidin"3s and underground public utility lines <br />//(including water, sanitary sewer and storm sewer). <br />Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />t�/ 4. Complete the "Authorization to Release Analytical Data" form. <br />El 5. Submit the appropriate fees and complete the "Underground <br />�/' Tank Program Fee Worksheet". <br />9�J 6. Procedures should expplain decontamination techniques if <br />applicable, material 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 Methal. <br />1I0 <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 />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 Wank Removals" for sampling criteria. <br />Gomppfete the San Joaquin Local Health District's (SJLHD) <br />"'Underground 'Tank Disposition Tracking Record". The holder <br />of the permit shall. be res onsible for ensuring that this form <br />is completed and returned he SJLHD. <br />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 insDection notice of at least 48 hours is re uired by <br />e gan Joaquin Lccar-Fe—a_ > iz5 -r is .AUlpropriate �a vance <br />ins c Yon no i ica of n ot�uris' c iono t ire district is <br />con rac ors res onsi-b tfY. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468.3820 <br />Environmen'.al Health <br />468-3420 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />