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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. <br /> Earl Pimentel,Vice Pres, 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,M.D. City of Lodi <br /> JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews <br /> Thomas Schubert,D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> San Joaquin County <br /> APP <br /> IT TO CLOSE <br /> ON <br /> UNDERGROUND STORAGEITANKS STOORRING HAZARDOUS MATERIALS <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> FACILITY SECTION: <br /> 1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> A. Obtain EPA Site Number from DOHS (916) 324-1781 for temporary hazardous waste removal <br /> activities associated with underground tank removals. <br /> B. Record name address, owner/operator, and telephone number of the location of the <br /> underground tanit(s). Include nearest cross street. <br /> CONTRACTOR SECTION: <br /> 1. Name, address, and telephone number of contractor performing removal activities. <br /> 2. Contractor's current California License and Class, along with proof of current Worker's <br /> Compensation insurance, or indicate if currently on f1e with this offppipce. pp <br /> 3. <br /> the "lplicationfire <br /> fordPermits strict to SJLHD. Ifthe <br /> thefire <br /> firredistrict <br /> districtrrequiresif athatcthee�JLHD permitirior to ubelissued <br /> prior to obtaining the necessary fire district permit, the fire district permit number shall be <br /> verified on site by SJLHD field personnel during tank closure activities. Failure to provide proof <br /> of fire district permit will result in cancellation of inspection. Reinspection fees will be charged <br /> for repeat visits. <br /> 4. Record the contracted laboratory's name and telephone number. 1*If contracted sampler is <br /> different from lab, record the name of sampling firm.] <br /> 5. Record the method of sample collection. <br /> CHEMICAL SECTION: (Do Not Write in Shaded Area) <br /> 1. List all materials stored, or previously stored, in the tank(s). <br /> GENERAL INFORMATION: <br /> 1. DISPOSAL INFORMATION: San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> removed from site. Tank(s) will be issued an identification number which SJLHD's representative will <br /> note on the Tracking Sheet and Contractor will affix same ID Number onto tank end using florescent <br /> spray paint. Undecontaminated tanks are to be transported under Hazardous Waste Manifest by a <br /> licensed hazardous waste hauler. <br /> 2. CONTRACTOR TO PROVIDE: Combustible/Flammable gas detector to verify LEL atmosphere of tank <br /> prior to lifting from excavation; adequate number and appropriate type of fire extinguisher, <br /> barriers to secure the area as necessary to minimize traffic and pedestrian interference; florescent <br /> spray paint to affix tank(s) identification number. It shall be project manager's responsibility for <br /> compliance with all health and safety precautions and requirements shall be strictly adhered to at <br /> all times during the course of the closure activities. <br /> CLOSURE IN PLACE: <br /> *If Closure ' lace ' su est d method of abandonment rel'minar soil borin s o othe <br /> condi lona sol s vor mus a comp e e odor o su m1 1ng DD Ica ton ar ecml or n eraround Tank <br /> closure a1n Droce urs ou 1ne en 1 e "P—reTtminary 51 a or or osure 1n ace" <br /> EH 23 045 <br /> Administration canicai Services Environmental Hearth Public Health Nursing <br /> :. 468-38M 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br />