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BOARD OF TRUSTEES S014 JOAQUIN LOCAL HEALTH DIS•ICT <br /> At Crow,Pres, SERVING <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Seey. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Meso M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Lodi <br /> Virginia Mathews City of Tracy <br /> Thomas Schubert D.V.M. City of Ripon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Stockton <br /> APPI.TSan Joaquin County <br /> UNDERGROUND STORAGCTITAANKSRSTO ING HAZARDOOR PERMIT TO US 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 Dolls (916) 124-1781 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 /> underground far, 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 Classr along vith proof of current Worker's <br /> Compensation insurance, or indicate if currently on file with this office. <br /> 1. Record the fire district and obtain the fire district permit, if applicable pprior to submitting <br /> the "A plication for Permit" to SJLHD. If the fire district requires that the �JLIID permit be issued <br /> prior to obtaining the necessary fire district permit, the fire district permit number shall be <br /> ofrfireddistrict ermitHwilleresultsinncancellattiontank <br /> ofcinspectionure �vrReinspectionFailure <br /> fees villlbe 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 /> 5. Record the method of sample collection. <br /> CHEMICAL 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 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 he 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 /> prior to lifting from excavation; adequate number and appLLuopriate type of fire extinguisher, <br /> arriets to secure the area as necessary to minimize tratfir- and pedestrian interference; florescent <br /> spray paint to affix tank(s) identification number. It shall. be project managyer's res ,onsibility [uc <br /> compliance with all health and • afetyy precautions and requirements shall be st[ictly 5,Sonsib li at <br /> all times during the course of the closu[e activities,) hered <br /> CLOSURE IN PLACE: <br /> tIf Closure 'n Place is su es ted method of abandonment reliminar soil borin s nr nlhe[ <br /> condi Iona sal s wor mus a com e e ttlnr o su mI In <br /> osure aIn ince uca OUEJ en I e re Im anti e arra aril ourrrmn ME mer round Tank <br /> Ell 21 045 <br /> Administration Clinical Services <br /> 468-3400 Environmental Health Public Health Nursing <br /> 468-3830 468-3420 <br /> Air Pollution <br /> 468.3860 <br /> Community Services <br /> 468ry, <br /> Laboratory WIC <br /> 468-3620 468-3460 - <br /> 468.3280 <br /> AIDS Information 468-3820 <br />