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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Prot San Joaquin County <br /> Earl Plmantek Vice Prez 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.Mask M.D. JOGI KHANNA. M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> p Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams.PhD. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> AGILITY SECTION: <br /> 1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE'. <br /> A. Obtain EPA Site Number from DHS (916) 124-1781 for temporary hazardous waste removal <br /> activities associated with underground tank removals. <br /> B. Record name address, ovner/operator, and telephone number of the location of the <br /> underground tani(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 Classalongg with proof of current Yorker's <br /> Compensation insurance, or indicate if currently on file vith this office. <br /> 1. 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 SJLHD permit bel issued <br /> ���fff prior to obtaining the necessary fire district permit, the fire district permit number shall be <br /> verified on site by SJLHD field perscnne] 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 /> t 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 fir a, 1 <br /> 5. Record the method of sample collection. <br /> C ENICAL 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 accom any each tank <br /> removed Ecom site. Tank(s) will be issued an identification number which SJLIID's representative will <br /> note on the Tracking Sheet and Contractor will affix same ID Number onto tank end 'Ing 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/Flanmable gas detector to verify LEL atmosphere of tank <br /> Brfor to lifting iron excavation; adequate number and appropriate type of fire extinguisher- <br /> arriers 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 piecautions 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 In Place is suggested method of abandonment, orellninaTV sail borin o� or outer <br /> condi lona sol s vo[ , nus a co■ e e n or n su nI In "A illcaEion fn[ Perritt for Underground Tank <br /> osure a n rocs ora ou Ins en 1 e re Imt1a� . 1 a orTT-CTsure If Place.. <br /> EH 21 045 <br /> Administration Clinical Servicos 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 468.3820 <br />