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)0 <br />*1116= OF TRUSTEES <br />At d1ow, PM <br />Earl Pime". Vice Pros. <br />Tommy Joyce, Sec'y. <br />James F. Culbertson <br />John D. Mast M.D. <br />Virginia Mathews <br />Thomas Schubert O.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />E <br />1601 East Hazelton Avenue <br />Stockton, California 95205 <br />11 <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />!011 4118REQNIZA, DZ 4 a <br />Aa1LD-ZYM01* �# ZttUW#3 <br />GENERAL <br />INSTRUCTIONS: <br />1: Submit all information in triplicate. USE CARBONS. <br />;Z2. Include a detailed site map showing tank location and type, <br />piping, streets and adJacent properties (north toward the <br />top o thepa e) location of nearby septic tanks, <br />leachliels gulidings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />i <br />3. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE". <br />24. Complete the "Authorization to Release Analytical Data" form. <br />5, Submit the appropriate fees and complete the "Underground <br />Tank Program Fee Worksheet". <br />SERVING <br />tan 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 />6. Procedures should explain decontamination techniques if <br />agRlicable, materials) utilized for rinsate, transportation <br />a/or storage of hazardous waste generated on site, and <br />specify the responsible p4rty(jes) who will be disposing of <br />waste generated on site. A aAt " /.zz/LS, <br />�ela 7,.c <br />7,,/ Procedures should explain purging and 7or i'nerting method. <br />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 />t 0. Complete the San Joaquin Local Health District's (SJLHD) <br />"Underground Tank Disposition Tracking Record". The holder <br />of the permit shall responsible for ensuring that this form <br />is completed and returned the SJLHD.' <br />,0 10. The maximum review time for <br />__-----,,.from the date of receipt of <br />11. "I A <br />Closure Plans is 15 working days <br />the adequately completed Plan. <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 />468-3620 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />