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.-_ -�JIY fJ Vii.-+..� - ^.�:�'ce`,._+.�.-r °�„�k.^..,.�'a_.�..� ..k.4 s^-3? ~••-~-��:4 +v �'.a':. '��-ti-s!..�:-•�- -�-t-� -f�F 1 . BOARD of TRusTEES SAN JOAOUIN LOCAL.HEALTH DISTRICT WAWNG San Joo"Couny AlCrow,Prq. Al •. PlmtM vaa pr„ 1601 East Hazelton Avenue C*of Manteca EanTommy Josh may- Stockton.Califomia 952M . , Chy a F.scaW Jamas F Culc.rUon uy a L" John a Mast M_O. JOGI KHANNA, Mtn., M.P.H. DISTRICT HEALTH OFFICER City of Tisch vuginla Morse" Cly 61 tarpon Thomas schubftL C-VAL San.JpaQwir�Count' Daphne Stow city a swum ' Harvey%Mlusmf,PhD. San Joaquin Count' APPLICATION FOR PERMIT TO CLOSE L)NDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS ' INSTRUCTIONS FOR CWLETING TRIS FOM FACILITY SECTION: 1. Complete fora "APPLICATION FOR PERMIT FOR UNDERGROUND ?INK CLOSURE". ' A. Obtain EPA Site Humber from DHS (115) 324-1181 for temporary hazardous vaste removal activities associated with underground tank removals. ' S. Record name address, ovner/operator, and. telephone number of the location'of the underground tani(s). Include nearest cross street. CONTRACTOR SECTION: ' 1. Name, address, and telephone number of contractor performing removal activities. 2: Contractor's current California License and Class, aloe vith proof.-Of current Worker's Co ' mpensation insurance, or indicate if currently on file with this office. 3. Record the fire district and obtain the fire district,perait,_if apppplicable( pprior to submitting the "application for Pernit". to SJLtfD. If the fire district requires {Fat the SJLHD permit be issued prior to obtaining the necessary fire district. perait, the fire district permit number shall be verified on site fry SJLHD field'personnel during tznk closure activities. Failure to provide proof of fire district permit will result in cancellation of inspection. Reinspection fees will be charged for repeat visits. 1. Record the contracted laboratory's name and telephone number. ['If contracted sampler is ' different from lab, record the name of sampling fira.l 5. Record the method of sample collection. CHEMICAL SECTION: (Do Not Write in Shaded Ureal 1. List all materials stored, or previously stored, in the tank(s). GENERAL INFORMATION: 1. DISPOSAL INFORMATION: San Jeaquin Local health District's Tracking Sheet vill accompany each tank removed from site. Tank(s) will be issued an identification number which SJUID's representative will note on the Tracking Sheet and Contractor will affix same ID Number onto tank end using florescent spray paint. Undecontaninated tanks are to be transported under Hazardous Waste Manifest by a licensed hazardous waste haul-er. 2. CONTRACTOR To PROVIDE: Combustible/Franmuble qas detector to verify LEL atmosphere of tank e prior to lifting fron excavation; adequate number and a prupriate type of fire extinguisher* barriers to secure the area as necessar to minimize traIic and pedestrian interference; florescent spray paint to affix tank(s) identification number. It shall be project mana eels resFFonsibility for compliance with all health and safety precautions and requirements shall be s rictly adhered to at all times during the course of the closure activities. CLOSURE IN PLACE: 'If Closure in Place is Suc:ested netliod of abandonment relininary soil borin s or other condi lona S01.5 work.. xLs[ a ccs a:e Prior o subi1-tiro !ca lcn or Permit .ar n e; round Tank osure AtaSn GlDctci:d Cut- entlt ea kre Iftina v 1 �o•k rc o urr n EH 23 015 1 Adm+nislr860n Clinical Services Environmemal F"Im Public Neanri Nursing 4"_34Oo 468.3850 468-7420 -458-3860 ' Air Ponuiuon Community Services LBaorsiory WC 468-3470 468.3en 466-3460 468.32tA 244