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t. <br />BOARD OF TRUSTEES <br />At Crow, Pres. <br />Earl Plmentel, Vice Pres. <br />Tommy Joyce, Secy. <br />James F. Culbertson <br />John D. Mast, M.D. <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />INSTRUCTIONS <br />FACILITY <br />1. Complete f <br />• JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />San Joaquin county <br />1601 East Hazelton Avenue City of Manteca <br />Stockton, California 95205 City of Escalon <br />City of Lodi <br />JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />IND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />COMPLETING THIS FORM <br />"APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br />A. Obtain EPA Site Number from DHS (916) 314-1781 for temporary hazardous waste removal <br />activities associated with underground tank removals. <br />H. Record name address, owner/operator, and telephone number of the location of the <br />undermroun tank(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 Class/ along with proof of current Worker's <br />Compensation insurance, or indicate if currently on file with this office. <br />3. Record the (fire district and obtain the fire district permit,if apppplicable pprior to submitting <br />the "Application for Permit" to SJLHD. If the fire district requires that the - NO permit be issued <br />prior to obtaining the necessary fire district permit, the fire district permit number shall be <br />verified on site by SJLHD field personnel during tank closure activities. Failure to provide proof <br />of fire district permit will result in cancellation of inspection. Reinspection fees will be 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.l <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 />I. 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 SJLI(D'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 be 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 liftit from excavation; adequate number and appropriate type of fire extinguisher, <br />barriers to secure the area as necessaip to minimize traffic and pedestrian interference; florescent <br />spray paint to affix tank(s) identification number. It shall be project manager's responsibility 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. <br />CLOSURE IN PLACE: <br />EH 23 045 <br />Adminlstratio <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3830 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />AIDS Information 468-3820 <br />Laboratory <br />468-3460 <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3280 <br />