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DISTRICT SERVING <br /> R(11ARD OF TRUSTEES SAN JOAQUIN LOCAL WEALTH DIS San Joaquin County <br /> AlCrow,Pres. City of Manteca <br /> " 1601 East Hazelton Avenue City of Escalon <br /> Earl Pimentei,Vice Pres. Stockton, California 95205 City of Lodi <br /> Tommy Joyce,Secy. City of Tracy <br /> James F.Culbertson JOGI KHANNA, M.D., M.P.W. DISTRICT HEALTH OFFICER City of Ripon <br /> John D.Mast,M.D. San Joaquin County <br /> Virginia Mathews City of Stockton <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw <br /> Harvey Williams,Ph-D- <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 <br /> NDER 1R 81 o <br /> Nprenpohazardous waste removal <br /> AtOaCy <br /> A. Obtain EPA Site Number from DHS (916) 324 <br /> activities associated with undergr.onnd tank removals. <br /> B, Record name address, owner/operator, andttellephone number of the location of the <br /> underground tani(s). Include nearest <br /> CONTRACTOR SECTION: <br /> 1. Name, address, and telephone number of contractor performing removal activities. <br /> ith <br /> 2. Contractor's current California Licenseeand Consf lelvi�hwthispofficef current Worker's <br /> Compensation insurance, or indicate pppp ppto <br /> 3, Record the fire district and obtain the <br /> etfir district <br /> Peraegairesathatcthee�JLHi)opermitubelissued <br /> the "A plication for Permit to S Provideroof <br /> prior to obtainingq the necessary fit <br /> district permit, <br /> the fire district permit number shall e <br /> ivities <br /> verified on site by SdLHY field personnelnddurin?iolla nnofcinspectlosure ion. Rein spectionrfee:i willbecharged <br /> of fire district permit > <br /> for repeat visits. <br /> 4. Record the contracted laboraameyof sampling fits vane number. i*If contracted sampler is <br /> different from lab, record the <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: th <br /> 1, DISPOSAL INFORMATION: San JoabelissuedlHealan identificationsnumberiwhichaSJLHDn� Sheet 1s reoresen�ative will <br /> removed from site; TanM s) will onto <br /> note on the Tracking Sheet and Contractor will affsported undermHazardoustWaste nManifestfbyrascen <br /> spray paint. Undecontaminated tanks are to be trans <br /> 11censed hazardous waste hauler. <br /> of tank <br /> 2. CONTRACTOR TO PROVIDE: Combustible/Flammable gas detectrka�o te1efofLfrtretextpnguishefforescent <br /> pprior to lifting Elon excavation; adequyyate number and a pprop Yp <br /> barriers to secure the aarea a nese fication inimize Ira hallabe project;manangerlserescponsibility for <br /> spray paint to affix t ( ) precautions and requirements shall be strictly adhered to at <br /> compliance with all health and safety p <br /> all times during the Course of the closure activities. <br /> CLOSURE IN PLACE: <br /> *If Closure in Place is suggested method of abandonment canion soil erii °orr other <br /> Tank <br /> condi Iona sat s wor TOUS e com e e IIOr o sia ni "i n` ""AA 11 <br /> sin Ioce urs ou ine en a re iminaSIRor or o ure inTace •. <br /> a5llre .EN 23 23 045 - <br /> Environmental Health Public Health Nursing <br /> Administration Clinical services 468-3420 468-3860 <br /> 468-3834 `�" <br /> 468-3400 <br /> Laboratory WIC <br /> Air Pollution Community Services Laboratory <br /> 468-347© 468-3280 <br /> 4fi8-3820 <br /> a1Dc lnform0on 468-3820 <br />