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UIN LOCAL HEALTH DISTRICT <br />SAN JO/ San Joaquin county <br />JARO OF TRUSTEES City of Manleca <br />Al Crow, Pres. 1601 East Hazelton Avenue City of Eacelon <br />Earl Plmentel, Vice Pres. Stockton, CBilfornia 95205 City of Lodi <br />Tommy Joyce, Secy. City of Tracy <br />James F. Culbertson JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Ripon <br />John D. most M.D. San Joaquln County <br />Virglnin Mathews City of Stockton <br />Thomas Schubert D V.M. San Joaquin County <br />Daphne Show <br />Hervey Williams, Ph.D. CLOSE <br />APPLICATION FOR PERMIT TO <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 tempoCLOSUrary <br />Bhazardous waste removal <br />1 for <br />aA. ctivities associated Number flog undergroundltank2remov,1IS, tenpora[y <br />B. Record name addrelncludeeneaiesttcrossnstteetPhone mumbo[ of the location of the <br />CONTRACTOR SECTION: tractor performing removal activities. <br />1. Name, address, and telephone numbe[ of con <br />CoepContract i'sucurrent Californiae licenseeand <br />yCOnsfilelvlEh thispofficeE current Worker's <br />ot pppp p permit be issued <br />the RAcppplicthe aH onfire <br />Eotdistrict <br />pernit" todSJLtIDtn if therfiresdistricctr[equitesathetcthee§number to submitting <br />prior to obtaining t4JLHDcfieldypfile ersonneltdu[inQetank closure act district feet, will provide <br />verified on site y g <br />of Etre district permit will result in cancellation of inspection. Reinspection feet, will be charged <br />for repeat visits. <br />4.EERecord <br />Etthe <br />contracted laboratthe ory's of name sampling telephone <br />�iione number. iflE contracted sampler is <br />erent <br />lab <br />5. Record the method of sample collection. <br />CHEMICAL SECTION: (Do Not Write In Shaded Areal in the tank(s). <br />1. List all materials stored, or previously stored, <br />GENERAL INFORMATION: <br />1. D]SPOSAL INFORMATION! San Joaquln Local Health District's Trackingg Sheet v111 aeapresenyy ative each tan <br />remoremoved ed themTsite. TShcet)awill <br />nd be issued lctol vill)aEEixfsaneilD Number oon number wntohtank 14end usingsflorescentlll <br />sppray paint. Under-ontanlnated tanks are to be transported under Hazardous Waste Manifest by a <br />licensed hazardous waste hauler. to p of tank <br />2pp.lorCONTRACTOR TOrPPROVezcavationl;usadequateanumber meable and as aepQtpQ[oprlate type Interference; fior <br />batrleto to secure the are as necessaryy to minimize traEEic and Qedejectlan Interference; rencppe; bilit cfor <br />s ca paint to affix tank(s) identificateon nimber.ons direquirementt shall be srshall bensttictly adheredltotatEo[ <br />compliance with all health and safety p <br />all times during the course of the closu[e activities. <br />EH 2] 045 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Servlces <br />468-3820 <br />Environmental Health <br />468-3420 <br />Laboratory <br />468-3460 <br />AIDS Information 468-3820 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468.3280 <br />