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`BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimenlel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert,D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <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 TANK CLOSURE". <br /> A. Obtain EPA Site Number from DHS (916) 324-1781 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 /> 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,iif applicable pprior to submitting <br /> the "Appplication for Permit" to SJLHD. If the fire district req ures <br /> that the �JLHD 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. Mf 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 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 lifting from excavation; adequate number and appropriate type of Eire extinguisher• <br /> barriers to secure the area as necessary to minimize traffic and pedestrian interference; florescent <br /> spray paint to affix tanks) identification number. It shall be project manager's responsibility for <br /> complince 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 /> A <br /> 1 *If Closure in Place is so ested thod abandomnt relimns or"o.ther <br /> um <br /> o11 <br /> n aonor rnioriCa n ergr <br /> ro�und Tankcondi lona soils worknus com e e r Fo <br /> Closurece ural outline en i e -Preliminary site work Fo—r-75'suren a�ca <br /> EN 23 045 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468.3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />