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~ <br />JAAD OF TRUSTEES SAN JOA%. IN LOCAL HEALTH DISTRICT *./ SERVING <br />Crow, Pres. San Joaquin County <br />Ead Pimentel, Vice Pres. 1601 East Hazelton Avenue City of Manteca <br />Tommy Joyce, Secy. Stockton, California 95205 City of Escalon <br />James F. Culbertson City of Lodi <br />John D. Mast, M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />Virginia Mathews City of Ripon <br />- <br />Thomas Schubert D.V.M. San Joaquin County <br />' r. <br />Daphne Shaw City of Stockton <br />Harvey Williams, Ph.D. San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />h" <br />UNDERGROUND STORAGE TANKS S'T'ORING HAZARDOUS MATERIALS <br />w <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 DHS (916) 324-1181 for temporary hazardous waste removal <br />activities associated with underground tank removals. 41-6'L'( fZry Vc�'(,VeTz RFcWi123D To cY1c�. <br />B. Record name address, owner/operator, anc telephone number of the location of the <br />tariffs), <br />underground In,nearest cross street. <br />CONTRACTOR SECTION: <br />ls' <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 pprior to submitting <br />the "Application for Permit" to SJLHD. If the fire district requires that the �JL,D permit be issued <br />prior to obtainingthe necessary fire district permit, the Eire district permit number shall be <br />verified on site y 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 />i <br />5. Record the method of sample collection. <br />.- <br />'HEMICAL SEC?ION: (Do Not Write in Shaded Area) <br />1. List all materials stored, or previously stored, in the tank(s). <br />3EHERAL INFORMATION: <br />1. DISPOSAL INFORMATION: San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />f <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 />pL10L to lifting from excavation; adequate number and appropriate type of fire extinguisher• <br />barriers to secure the area as necessaryy to minimize traffic and pedestrian interference; florescent <br />spray paint to affix tank(s) identificaEion 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 />j, <br />ZOSURE IN PLACE: <br />trf <br />;H 23 045 <br />Administration Clinical Services Environmental Health Public Health Nursing <br />468-3400 468-3830 468-3420 468-3860 <br />Air Pollution Community Services Laboratory WIC <br />468.3470 468.3820 468-3460 468-3280 <br />AIDS Information 4,68-3820 <br />