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mo ARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> San Joaquin County <br /> Al'row,Pra. <br /> Ban Pimentol,Vice Pra, 1601 East Hazelton Avenue City Of Manteca <br /> Tommy Joyce,Sx'y, Stockton, California 95205 City of leecelon <br /> James F,Culbertson City of Lod, <br /> John D.Mut,M.D. J001 KHANNA, M.D., M.P.N., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathmws ' Cly of Ripon <br /> Thomas Schubert O.V.M, Sen Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO HOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> FACILITY SEC'T'ION: <br /> 1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> A. Obtain EPA Site Number from DOIIS (916) 324-1781 for temporary hazardous waste removal <br /> activities associated with underground tank removals. <br /> R. Record name, address, ovner/operator, and telephone number of the location of the <br /> uuJrL4Lvuud tanR(a). Include neareat oroca atreet. <br /> CONTRACTOR SECTION: <br /> 1. , Name, address, and telephone number of contractor performing removal activities. <br /> 2. Contractor's current California License and Classy along with proof of current Worker's <br /> Compensation insurance, or indicate it currently on file vi h this office. <br /> 3. Record the fire district and obtain the fire district permit, if apppplicable Prior to submitting <br /> the "Application for Permit" to SJLHD. If the fire district requires that the 9J HD 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. (elf contracted sampler is <br /> different from lab, record the name of sampling firm. ) <br /> 5. Record the method of sample collection, <br /> CHEMICAL SECTIONI (Do Not Write In Shaded Area)I <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/Plammable gas detector to verify LEL atmosphere of tank <br /> t[�riD <br /> oC to lifting ftom excavation; adequate number and appropriate type of fire extinguisher, <br /> aIrie rS to secuT P. the area as nece55aIy to minimize tT at tic and pedestrian interference; florescent <br /> s rayy aint to affix tank(s) identification number. It shall be project manager's responsibility for <br /> coop]fance with all health and safety precautions and requirements shall be strictly adhered to at <br /> all times during the cuursa ul the closure Activitfes <br /> CLOSURE IN PLACE: <br /> a e met f abandon a Telimina s it burin s of <br /> andl Ina v e e Ito a mi i Ica ro or permit tor u <br /> ciosure",--uptain proceaurale n e . <br /> EH 23 045 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 408.9400 468.3830 468-5420 468.38W <br /> Air Pollution Community Services Laboratory WIC _ <br /> 488.3470 468.3820 468.3400 468.3780 <br /> AIDS Information 468.3820 <br />