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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DIST I <br /> At Crow,Pres. ..T SERVING <br /> Earl Plmentel,Vice Pres. 1601 East Hazelton Avenue - San Joaquin County <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mask 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 /> APPLICATIT TO CLOSE San Joaquin County <br /> ON <br /> UNDERGROUND STORAGE ITANKSRSTOOR RING HAZARDOUS MATERIALS <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> FACILITY SECTION: <br /> I. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> A. Obtain EPA Site Number from DNS (916) 321-1781 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 tank(s). Include nearest cross street. <br /> CONTRACTOR SECTION: <br /> I. Name, address, and telephone number of contractor performing removal activities. <br /> 2. Contractor's current California License and Class alongy with proof of current Worker's <br /> Compensation insurance, or indicate if currently on file vlth this office. pp <br /> ord <br /> the °Apcplication1fordPermit" and obtain <br /> Ifetilerfiresdistrictrrequiresathatcthee�JLHDopermitubeiissued <br /> verified on site <br /> i tengytgjLllo fieldyPersonneltdoringpetcrnk,closure activities.peFalluremtorpcovitlebpr6of <br /> of fire atsvisit permit will result in cancellation of inspection. Reinspection fees will. be charged <br /> for repeat visits. <br /> 1. 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 /> 1t 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 SJUID's representative will <br /> note on the Tracking Sheet and Contractor will affix same ID Number onto tank end using florescent <br /> spray paint.hazardous <br /> waste atedhaul tanks are to be transported under Hazardous Waste Manifest by a <br /> licensed hazardous waste hauler, <br /> p2. CONTRACTOR TO PROVIDE: Combustible/Flammable gas detector to verify LEL atmosphere of tank <br /> barriers to tsecurer the areaaasonecessaiyuato minimize traFEicpand tpedestrianfire <br /> interference; florescent <br /> spray paint to affix tank(s) Identification number. It shall be project managerrs 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 /> condi*ionaClosure <br /> stvorPlace <br /> nusts euLq comsP—Ttodenet[todoroEoasUnnonmeht relicanaan sort ermtn sort nteerround Tank <br /> psora a n core ora ou the en e r tmtpa t o o 0 0 ore n ace <br /> EH 23 015 <br /> Administration Clinical Services Environmental Health <br /> 468-3400 468-3830 Public Health Nursing <br /> 468.3420 468-3860 <br /> Air Community Services <br /> 468-348-34 700 468-3820 Laboratory WIC <br /> 468-3460 468.3280 <br /> AIDS Information 4aa-rta2n <br />