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BOARD OF TRUSTEES <br />Al Crow, pro& <br />Earl Plmenlel, Vice Pres. <br />Tommy Joyce, Sedy, <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey IMIllems, ph.D. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />1601 East Hazelton Avenue San Joaquin county <br />Stockton, California 95205 City of Manteca <br />City of Escalon <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />I, GENERAL INSTRUCTIONS: <br />I. Submit all information in triplicate. USE CARBONS. <br />2. Include a detailed site map showing tank location and type <br />\ pipincl, streets and adiacent properties (north toward the ' <br />top off the page) locaEtion of nearby septic tanksr <br />leachfields u idings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />�9 3. QOmpleeENK <br />te form "APPLICATION FOR PERMIT EOR UNDERGROUND TA <br />4. Complete the "Authorization to Release Analytical Data" form. <br />Q� 5. Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />16. Procedures should expplain decontamination techniques if <br />ls) <br />applicable, materiautilized for rinsate, transportation <br />al /or storage of hazardous waste generated on site, and <br />specify the reEponsible party(ies) who will be disposing of <br />waste generated on site. <br />f '7. Procedures should explain purging and/or inerting method. <br />L❑ 8. 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 />CP 9. Compplete the San Joaquin Local Health District's (SJLHD) <br />of nthegrpeozmitlshal/ibporesplorlsIblekfo ensuring that thiseform <br />is completed and returned L -he SJLHD. <br />❑ 10. The maximum review time for Closure Plans is 15 work.inq days <br />from the date of receipt of the adequately completed Plan. <br />❑ 11. AdvanrP <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />460.3400 <br />Air Pollution <br />468.3470 <br />Clinical Services <br />468.3030 <br />Community Services <br />460.3820 <br />Envlronmen!al Health <br />468.3420 <br />Laboratory <br />406-3460 <br />Public Health Nursing <br />468-3960 <br />WIC <br />468.3280 <br />