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7 <br /> �• �"�r. Sc��vi� 1.C?.s� a .RF •axaas+a.�. i%ii?3e. t'�' - - �- � lei <br /> - --- - - - - .P� � •:-�•, - - ��#�� tom#^-�i�' � " . <br /> 5itsxr;m <br />� 6® <br /> r' <br /> I OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVINu <br /> ,w,Net. San Joaquin'County <br /> tlmenlel,Vtca Pres. 1601 East Hszellon Avenue City of Manteca <br /> ,my Joyce,sec y. Stockton,California 95205 Cly of Esealon <br /> .s F.Culbertson City of Loll <br /> ).Mast,M.D. JDQI XHANHA, M.D., M.P.H., DISTRICT HEALTH OPFICER City ul Tracy <br /> nIrv.nfa Mathews Cly of Alpon <br /> homas Schubert,D.V.M. Bart Joaquln County <br /> Dnphns Shaw City of Stockton <br /> Harvey Wllllams,Ph.D. San Joaquin Couny <br /> APPLICATIO14 FOR PERMIT TO CLOSE <br /> LINDERGROLTID STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> .y INSTRUCTIONS FOf1 COMPLETING THIS FORM <br /> FACILITY SECTION: <br /> 1. COPPIete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE", <br /> A. Obtain 9PA Site Number from DRS (416) 324-1981 for temporary hazardous Paste tenoval <br /> activities associated vith underground tank removals. <br /> B. Record name address, ovner/operator, and telephone number of the location of the <br /> underground tan((s). Include nearest cross street. <br /> CONTRACTOR SRCTION: <br /> I. Hain,,address, and telephone number of contractor performing removal activlties,:: <br /> 2. Contractor's current Callfornia License and Class along vlth proof of current vatkat'm <br /> Compensation Insurance, or Indicate if currently nn ,Hie vl�h this office <br /> 3. Record the fire district and obtain the fire dl.,crlct e.rmlt If ap llcable pIor to tabai ting <br /> the °Application for permit' to SJLND. If the fire district requires teat the JLHD petmi be asued <br /> prior to obtainingg the necessary fire district permit, the fire district permit numbee SRI"- e <br /> verified on site by SJLi1D field personnel during tank closure'activltles. Failure to protide proof <br /> of firbe <br /> e district permit vill result in cancellation of inspection. Reinspection fees vlil be charged <br /> for repeat visits. <br /> 4. Record the contracted laboratory's name and telephone number. [fit contracted sampler Is <br /> different from lab, tecard the name of sanpling fira.l . <br /> .5. Record the method of sample collection. <br /> CNEMICAG SEC7ION: (Do Bak Write In Shaded Area) <br /> a.} I. Gist all materials stored, or previously stored, in the tank(sI. <br /> P�:�ERAG INFORMATION: <br /> I. DISPOSAL INFORMATION: San Joa uin Local Health Disirict's Tracking sheet V111 accoppanY each tank <br /> removed from site, Tank(sl vilI a Issued an Identification number vfiich SJLIID'S representative will <br /> 'note on the Tracking Sheet and Contractor vlll affix same ID Number onto tank end using florescent <br /> Ipaint. Undecontaminated tanks are to be transported under Hazardous Waste Manifest by a . <br /> Ilcensed hazardous waste hauler. <br /> 2. CONTRACTOR TO PROVIDE: Combustible/Flammable as detector to verify LEL at as of tank <br /> .lar to lifting Eton excavation; adequate number Ind appropriate type gE mite extlngulahe <br /> pIrlel:s ta_secure the-area as necessary-to-mJnimlze traffic and-pedestrian interference, - florescent- <br /> to <br /> ray paint to affix tanks► Identiflca ion nurbet. it shall be pro}}ect Danaget's tea ponsibittlty for <br /> mpliance with all-health and safety precautions and requirements shall be sttictly adhered to at <br /> all tines during the course of the ciosute activities. <br /> CLOSURE 10 PLACE: <br /> a osure In t ace Is ogg estjee <br /> leethv v a and t fg�m a o a <br /> ondl n s wv mu; a roe t: r o s a n a o mILI her <br /> ,�g�gl�dlank <br /> u e�I a <br /> wr <br /> EN 23 045 <br /> Adminlelrslion ClInIcal 5ervicea Environmental Hoalth <br /> 408.3400 488-38x0 Public Health Nur1In0 <br /> ABn•5420 �0a•3580 <br /> Air Pollution Community Servfoes f aboralory ylylC <br /> 48a-3470 488-3820 488-3400 408•3290 <br /> AIDS Informallon 408.3820 <br />