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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DIST IIC <br /> Al Crow,Pre& � SERVING <br /> ,_all Plmentel,vice Pres. 1601 East Hazelton Avenue San Joaquin County <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Manteca <br /> James F.Culbertson City of Escalon <br /> John D.Mast,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 Hipon <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. City of Sloeklon <br /> San Joaquin County <br /> UNDERCROUNDASTORAGCTITANON KS RSTORING TOIT CLOSE <br /> 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 /> 0. Record na a address, owner/operator, and telephone number of the location of the <br /> underground tan�(s). Include nearest cross street. <br /> CONTRACTOR SECTION: <br /> 1. Name, address, and telephone number of contractor performing removal activities. <br /> ?. Contractor's current California License and Classy alongq with proof of current Worker's <br /> Compensation insurance, or indicate if currently on file wlih this office. <br /> 3. Record the fire district and obtain the fire district permit, if applicable pprlor to submitting <br /> the •Application for Permit" to SJLIID. 11 the fire district requires that the �JLHD permit be Issued <br /> prior to obtatnin the necessary fire district perult, the fire district permit number shall be <br /> verified on site 2y SJLIID field persunhel during tank closure' activities. Failure to provide proof <br /> of fire district permit will result in cancellatiun of inspection. Reinspection fees will be charged <br /> for repeat visits. <br /> 4. Record the contracted laboratory's name and telephone number. ItIf contracted sampler is <br /> different from lab, record the nave 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 /> I. DISPOSAL INFORMATION: San Joaquin Local health District's Tracking Sheet will accompany each tank <br /> removed f(o■ site. Tank(s) will be issued an identlflcation number which SJLIIU's representative will <br /> note on the Tracking Sheet and Contractor will affix sage ID Number onto tank end using t1orescent <br /> spray paint. Undecontanlnated tanks are to be transported under Hazardous Waste Manifest by a <br /> licensed hazardous waste hauler. <br /> 2. CONTRACTOR TO PROVIDE: Coabustible/Flammable gas detector to verify LEL atmosphere of tank <br /> prior to lifting from excavation; adequate number and alj)ropriate type of fire extinguisher- <br /> barriers to secure the area as necessaryy to minimize traffic and pedestrian interference; florescent <br /> spray Paint to affix tank s) identiflcatlon number. ft shall be project ■ana er's respponsibility for <br /> coup lance with all health and safety precautions and requirements shall be strictl <br /> all tines during the course of the closure activities. y adhe[ed to at <br /> CLOSURE IN PLACE: <br /> *1f Closure In Place Is su ested method of abandonment r�elininar soil borin s or other <br /> condi lona sols woo nus a rmo , a erl— rtor 'n subnt tn, '11 ,]Ic;t ton or ern] or n errlround Tank <br /> oCT lure', a ,rocec urs o tnt. r e rr lu��l;i , <br /> �ASY._iS 1� Yoram cTir' o�j n�cc',..�. <br /> EH 23 045 <br /> Administration Clinical Services Environmental Health <br /> 460.3400 46©-3830 Public Health Nursing <br /> 468-3420 468-3660 <br /> Air Pollution Community Services Laboratory <br /> 468-3470 468-3820WIC <br /> 468-3460 468-3280 <br />