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BOARD OF TRUSTEES <br /> Pr <br /> Al Crow,Pres. SA"OAQUIN LOCAL HEALTH DISTRICT <br /> Earl Pimentek Vice Pres. SERVING <br /> Tommy Joyce,sec.y. 1601 East Hazelton Avenue <br /> James F.Culbertson Stockton, California 95205 San Joaquin County <br /> John D.Mas City of Manteca <br /> S M.D. JOGKHANN City of Escaion <br /> Virginia Mathews A, M.D., M.P.H., DISTRICT HEALTH OFFICER <br /> Thomas Schubert,D.V.M. City of Lodi <br /> Daphne Shaw Ciy of Tracy <br /> Harvey Williams,Ph.D. City of Ripon <br /> San Joaquin County <br /> City of Stockton <br /> UNDERGROUND APPLICATION FOR PERMIT San Joaquin County <br /> STORAGE TAS STORING HAZARDOCLOSUS PIA <br /> INSTRUCTIONS FOR COMPLETING THIS FOEUf TERIALS <br /> FACILITY SECTION: <br /> 1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> A. Obtain EPA Site Number from DHS (916) 324-1781 for tem <br /> activities associated with underground tank removals. <br /> B. Record name address, owner/operator, and telephone nu berrofhthe <br /> rewaste removal <br /> rdous <br /> underground tani(s), Include nearest cross street. <br /> CONTRACTOR SECTION: location of the <br /> CI. Name, address, and telephone number of contractor performing removal activities. <br /> ompensationoinsurance,ttoraindicate ifccurrentlyConsfilelvifhwthis office. <br /> proof of current Worker's <br /> 3. Record the fife district and obtain the Tice district permit, if a plicable rior to submitting <br /> the "Application for Permit" to SJLHD. If the fire district requires <br /> of Prior o obtaininified og the necessary fire district l duringgpermit, the fire districRp permit nuppNber shall be <br /> forf epeats ie din sitpermitHWilleresultsino�ancellatitank cinOsuxe spection�vrRe t permit number shat be issued <br /> for repeat visits. <br /> fees willibe charged proof <br /> 4• Record the contracted laboratory's name and telephone number. t <br /> different from lab, record the name of sampling term, ( <br /> S• Record the method of sample collection. ( If contracted sampler is <br /> IEMICAL SECTION: (Do Not Write in Shaded Area) <br /> I. List all materials stored, or previously stored, in the tank(s). <br /> NERAL INFORMATION: <br /> re DISPOSAL INFORMATION: San Joaquin Local Health District's Tracking Sheet will accostn <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 it <br /> spray Paint. Ing <br /> tanks are to be transported under Hazardous Waste Manifest aach tank <br /> licensed hazardous waste hauler. <br /> using florescent <br /> p2• CONTRACTOR TO PROVIDE: Combustible/Flammable gas detector to verify LEL atmosphere of tank <br /> barof riers tofsecurertheeareaaasonecessaippuatoo minimizentrappppic and pedestrian interference; florescent <br /> se,Pt paint to affix tank(s) identification number. It shallrbetprojectomanacerestcesuonslbility 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. scent <br /> ]URE IN PLACE: <br /> *If <br /> i Closure in Place is su ested method of ba <br /> lona so s vor mus a com a rio o monment ilgel inar soil borin s or other <br /> ure sin roce urs ou i e en in <br /> 3 045orfs ion r e i o[ n er round Tank <br /> 0 osu n ace . <br /> Administration <br /> 468-3400 Clinical Services <br /> - 468-38M Environmental Health <br /> Air Pollution 468-3420 Public Health Nursing <br /> 468-3470 Community services 468-3860 <br /> 468-3820 Laboratory <br /> 468-3460 WIC <br /> AIDS Information 468-3820 468-3280 <br />