Laserfiche WebLink
r <br />a <br />Y <br />+ i;e <br />WARD of TRt411TEBs SAN JOAQUIN LOCAL. HEALTH DISTRICT $mamma , <br />Al Crow, Pros. sen Joaquin County ;.. <br />Earl Pi��,, Vice priss. 1601 East. Hazelton Avenue city of Manteca <br />Tommy Joyce, Secy. Stockton, Califomla 95205 city of Escakin <br />James F. Culbertson City of Lodi <br />John D. Mast, M.D. Joel 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 Count' <br />Daphne Shaw City of Stockton <br />tNiniams, PhD. San Joaquin Count' <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />INSTRUCTIONS FM COMPLETING THIS FORM <br />FACILITY.SECTION: , <br />1. Complete fora "APPLICATION FON PERMIT FOR UNDERGROUND TANK CLOSURE". <br />A. Obtain EPA Site Number from DNS (916) 324-1781 for temporary hazardous waste removal r, <br />activities associated with underground tank removals. <br />B. Record name address, owner/operator, and telephone number of the location of the <br />underground tani(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 Claa alongg with proof of current WotketIS <br />Compensation insurance, or indicate if currently on ale with this office. <br />tRecord the fire district and obtain the fire district permit, if a plicable pprior to submltting' <br />he "Application for Permit" to SJLHD. If the fixe district requires Rat the SJLHD permit be issued" <br />Prior to obtaining the necessary fire dist ict permit, the fire district permit numbe% shall be' <br />verified on site 6y SJLHD field personnel �u�c in tank closure activities. Failure to prgvide roof , <br />of fire district permit will result in cancellation of inspection. Reinspection fees ri11 hanged,, <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 name of sampling firm.) ; <br />S. Record the method of sample collection.' <br />CHEMICAL SECTION: (Do Not Write in Shaded. Areal <br />1. List all materials stored, or previously storedr,in the tank(s). <br />GENERAL INFORMATIONt ° <br />1. DISPOSAL INFORMATION: Sanoaquin Local Health District's Tracking Sheet will accompan each tank £. <br />removed from site. Tank(s) will 6e issued an Identification number which SJLHD's reppresentative will; <br />note on the Tracking Sheet and Contractor will affix some ID Number onto tank end using florescent }r <br />s ray 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 tQ verify LEL atmosphere of tank ,> <br />prior to lifting from excavation; adequate number and appropriate type of fire extinguisher <br />barriers to secure the area as necessary to minimize traffic and pedestrian interference; florescent <br />spraypaint to affix tank(s) Identificaion number. It shall be project Nana en's reaponsf iliiy for ; <br />compiance with all health and safety precautions and requirements shall be Mictly adhered to at , <br />all times during the course of the closure activities.. <br />CLOSURE IN PLACE: <br />!Tf 111 jgj gj gbandll an nrallain.%vu &All hnrinne Ar nfhar2191 In R act -Is 699921 <br />}fry <br />EH 23 045 <br />.J <br />Administration Clinical Services Environmental Health Public Health Nursing � <br />-3400 468.3830 -3420 e <br />Air Pollution Community Services Laboratory NnC t <br />r <br />40-3470 488-3820 468 -SM 488.3280 <br />AIDS In tion 488.3820 ` <br />