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SERVING <br /> soiso of r�usTlEes SA� OAQUIN LOCAL HEALTH DISTI .T Samoa uin County <br /> AJ,Crow,Pre$. 1601 East Hazelton Avenue; City of Manteca <br /> Earl PlMntel,Vice Pres. City of Escalon <br /> i .,, Tommy Joyce.Secy. Stockton, California 95205 Ciry of Lodi <br /> James F.CulbertsonCity of Tracy <br /> John D.Mast,M.D. JOG1 KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Ripon <br /> Virginia Mathews /,,,� ,_ San Joaquin Cooney <br /> Thomas <br /> s Schubert.D.V.M. � f (j{JUI1}"1'! City of Stocl�ton <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. <br /> APPMATI1-4N FM PF: MIT TO i:l.,rQcl? <br /> UNDERGROl1ND STORAGE TAN 1:s STORING HA7.AC2DOI1� MATERIALS <br /> GEN-MAL INSTRUCTIONS: <br /> 1. Submit all information in triplicate. USE CARBONS . <br /> Q� 2. Include a detailed site map shuwiny tank location and type, <br /> pining, streets and adjacent prOPIrties (north toward the <br /> top of the pa9Q , location of nearby septic tanks, <br /> leachfields, buildings, and underground public utility line=s <br /> ( including water, sanitary sewer and store:; sewer ) . <br /> ❑ 3. (-.ompletE- form "APPT.,ICATION FOR PERMIT FOR UNDERGROUND TAtdK <br /> c2'OSUrd;". <br /> /4. Complete the "Authorization to Release Analytical Data" farm. <br /> Y 5. Submit the appropriate fees and complete the "Under.yr.ound <br /> Tank urogram F'eF Worksheet" `$ 90 <br /> [J G. procedures should explain decontamination, tectoniques if: <br /> ' applicable, material(s) utilized For rinsate, transportation <br /> and/or storage of hazardous waste generated on site, and <br /> specify the responsible p<artykes) who will be disposing Ot <br /> waste generated on site. , <br /> ❑ 7. Describe in detail flow soil and/or water samples, beneath the <br /> tank 's invert will be obtained. Refer to "CamPling ProtOCOI <br /> for Routins. Tank Removals" for "Pliny "j""' <br /> 8 . Complete the San Joaquin Local Health Di ;tr ice: ':, (SJLHD) <br /> "UndE.ground Tank bisposition Tracking Record" . Thr holder <br /> of the permit s:1311 be� responsible for ensuring that this furl", <br /> i, completed aro returned Lhu MAY <br /> ❑ 9. Advance inspection notice of at bast 46 ,h urs i.�r-Ltmti -e- <br /> i)Y <br /> the San Je:acai.n Local lll-!alth <br /> inspection notification of. uri�dir.t.io � fire- r'ai:�i:ri-_ 't= i_i <br /> contractor 's r.i,5pon:.,ibilitY- <br /> Id 10. � !t C 114 C,l> c, 11.(;(iU "1 <br /> EH 23 040 <br /> REVISED 12/88 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3830 468-3420 458.3860 <br /> 468-3400 _-_ — <br /> l,.tnorarory WIC <br /> Air Polluvon Gornmu Services 463.3280 <br /> 458-3474 <br /> 4613-38?.0 4613-341 <br /> 68 34(I-W) <br /> AIDS Information 4ee-31320 <br />