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J(AAD OF TRUSTEES SAN �AOUIN LOCAL HEALTH DISTRI SERVING <br /> Al,,row,Pres. Sam Joaquin County <br /> Earl Pirrentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce.Sec'y. 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 /> Thomas Schubert D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING 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 DNS (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 /> In'] <br /> underground tarilk(s). c ude 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 Classlalon ith proof of current Worker's <br /> Compensation insurance, or indicate if currently on If 1 e wl?hwthis office. <br /> 3. Record the fire district and obtain the fire district permit,,if I' bl ior to submitting <br /> the 11 lication for Permit" to SJLHD. If the fire district r equ resTatcatheehA&D permit be issued <br /> . 1p obtaining the necessary fire district permit, the fire district permit number shall be <br /> prior 0 <br /> verified on site by SJLHD field'personnel durin tank closure activities. Failure to provide proof <br /> of fire district permit will result in cancella?ion of inspection. Reinspection fees will be charged <br /> for repeat visits. <br /> 4. Record the contracted laboratory's name and telephone number. [tlf contracted sampler is <br /> different from lab, record the name of sampling firm. 1 <br /> 5. Record the method of sample collection. <br /> CHOMICAL 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 SJUID's representative will <br /> note on the Tracking Sheet and Contractor will affix same ID Number onto tank end using florescent <br /> spray paint, Undecontasinated 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 LUL atmosphere of tank <br /> grior to liftingfrom excavation; adequate number and app!opriate type of fire extinguisher, <br /> arriers to secu e the area as necessary to minimize traffic and pedestrian interference; florescent <br /> spraf,paint to affix tank(s) identification number. It shall be project mana er's responsibility for <br /> com t ? <br /> 1ptiance with all health and safety precautionstand requiremen s shall be s rictly adhered to at <br /> al mes during the course of the closure activi ies. <br /> CLOSURE IN PLACE: <br /> b2r- r other <br /> tIf Clos u,,ejt%,,,e a rg iminal, sq,, s- <br /> -n--l-M! in co Dle, !DLr9i4orOEoa�sun54m�iEn�L�innal'��6DIlILd an I Pe r oLnFgTnor UndergroUna Tal <br /> condiFio a soils wopriancgusPbs' <br /> Closure". Obtaia_kro�Ledural outiine entitieg "Preija_inary biLe wu[K for Closure In t'idi <br /> Ell 23 045 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-34DO 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 />