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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br />SERVING <br />San Joaquin County <br />At Cr ow, Pres. <br />ow. <br />1601 East Hazelton Avenue <br />City of Manteca <br />fed rol, vice Pres. <br />Tommy Joyce, Secy. Stockton, California 95205 <br />City of Escalon <br />468-3400 <br />City of Lodi <br />James F. Culbertson <br />John D. Mast, M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER <br />cityof Tracy <br />Virginia Mathews <br />City of Ripon <br />San Joaquin County <br />Thomas Schubert D.V.M. <br />Cityof Stockton <br />Daphne Shaw <br />San Joaquin County <br />Harvey Williams, Ph.D. <br />468-3280 <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />INSTRUCTIONS FOR COMPLETING THIS FORM <br />FACILITY SECT'ION: <br />1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br />A. Obtain EPA Site Number from DHS (916) 324-1781 for temporary hazardous waste <br />removal <br />activities associated with underground tank removals. <br />8. Record name address, owner/operator, and telephone number of the location <br />of the <br />underground tank(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 file with this office. <br />3. Record the fire district and obtain the fire district permit,if apppplicable prior to submitting <br />the 'Application for Permit" to SJLHD. If the fire district requires that the bLHD permit be issued <br />priorto 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. (*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 />ba criers to secure the area as necessary to minimize traffic and pedestrian interference; florescent <br />spray paint to affix tankls) 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 />ail times during the course of the closure act[vities. <br />CLOSURE IN PLACE: <br />EH 23 045 <br />Administration <br />Clinical Services <br />Environmental Health <br />Public Health Nursing <br />468-3400 <br />468-3830 <br />468-3420 <br />468-3860 <br />Air Pollution <br />Community Services <br />Laboratory <br />WIC <br />468-3470 <br />468-3820 <br />468-3460 <br />468-3280 <br />AIDS Information 468-3820 <br />