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<br />�SERVING
<br />t3QAYrt6 of TRUSTEES SAN JOAQUIN ..LOCAL HEALTH DIS RICT
<br />1.X`, San Joaquin County
<br />+ Ci ty-
<br />of MantecaAI Crow, Pres. �Z81tQ� A{eyq �CltgofEscatm
<br />Earl Plmentel,Vice Presn, California 952g5'1 �Cityof LodiTommy Joyce,
<br />, ^:James F. Culbertson Ity of Tracy
<br />.H., DISTRICT HEALT�(�f I i
<br />John D. Mass. M Dr\ f' I,Itc ,a a,l JO(iil K ti �►4a�'�r ., I� 6 ityt ?� Ripon
<br />Virginia Mathews „ ;- g '�"6 t; ;: San "Joaquin County '
<br />�,�a�� ;
<br />Thomas Schubert, D.V.M.City of Stockton
<br />Daphne Shaw A10 ; Inniormaagn 4b8.3�2¢t) San Joaquin County
<br />rvey Williams, PhA' 14 WF Y rj i f 5 f 7t i ,V F Fd�9U 9 i{%kk �i 1.1 tb bpi1s
<br />Ha f)
<br />t,MDERGRUtJNp STORA T S NG ALS
<br />INSTRUCTIONS FOR COLLETING THIS FORM
<br />CILITT< SECTIO
<br />�:fr 1 t r IF z Fr
<br />D$ OtJNQ� 13Y M
<br />f. 1 Complet furs "APPLICATION FQR PER - � r�
<br />as
<br />u SPA S1teNumbei� frost 32n 751, foxy azardous waste reaoval
<br />Obtain¢ ,
<br />'at ivitlessociated,
<br />N, o ew r g
<br />I, "-
<br />B. Record name, address' owner/operatiolE� ands telephone`'nOE be nf'pf the location of the
<br />I
<br />underground tank(s). Include nearest cross street. tl
<br />CONTRACTOR SECTION:``
<br />�' s gV acivit.ies.
<br />1. Name, address, all -,41
<br />� e�tp�>rber ���FoJn�ra or perfor.� � w pf �t � ��,.
<br />2 Cpnt>�actor� curd&nt�, �' f rp a1.Li.Sjp*e"-ind-Class alon rtitfi�pltool o, ':current Worker's
<br />g
<br />Co>I<pensat'ion insurance ' or''�Ind rate ii: f:urrently on file with this office.
<br />f „r
<br />3i Record the`�Eire district and obtain thg ire�4istr:ict paXit, if apppplicable pprior to submitting
<br />the ".A placation for-Peratt,7jp SJLHQ. ,.1 - h fi, Istri re ui
<br />tF►at the �JLHD permit be 1ps,�Ied'
<br />pp they ' ict.permit number shall be
<br />p>~Iot to obtaining tte necesaryftnfidi �`•p� ik,. [,4d r
<br />verified on site by SJLHD fi<e d per,sa� ne du in Unk�tiosur�e. v: tee .....k's, lure to provide proof
<br />of `Vice district perp�lt w��es.lk ib rfacei�la�an of inspectig1'gyp�tEtfspi�etion' fees will be ch>f;%'f
<br />for kepeat'arlsits.
<br />Cy xl ;tt ,%trt,.
<br />4. Record the.,contaacted Y�abo story's naag and telephone�nof. �E*if conhYhcted sampler,
<br />different'#tort` lab, record thjname of samp#
<br />ling >4m.1 V,r t ,,t
<br />5. Record the�`'aethod aft sample cwllecti'on. , ��
<br />t
<br />rY,116 St :; irY �•�
<br />CHEMICAL SECTION:r :(qo-Not trite `i"r ;Shaded Areal
<br />+.
<br />stored in the. }tank (s,)
<br />1. List.alh Materials stored; ` or prev os, 1 i Y
<br />tn r i
<br />GENERAL INFORMATION: , �,,,, �,%, 1,. �, It ��f,
<br />i r • • e i '� ,y- , r�, w � ".r:��,
<br />q A -. 6�+ `� t 1
<br />1. DISP4$AG.,INf'QRN�►TION
<br />an jpaquin; Lora; NeaxtD (I1istrict�� �ac>s,ing sb� t'�wi�r��accompain� each tank
<br />removed frof� asite. t1anklsJ Kili•'be tissyed an',identifica'tion nunii > wftich'JLND's represen alive will
<br />note on the wracking Street and Contractor vtll ffix same ID Number onto tank end using florescent
<br />spray paint :,;Undecontaminated tanks are Itq, be t ans�or'ted undet?'Nazsrddus"Wadte Nan'tfest;'by a
<br />licensed haia 4ous °,waste hauler
<br />2. CONTE TO PROVIDE: 'Combustible/Flammable gas detector to•veriy�`I',EL atmosphere of tank
<br />prior to lifting from excavation; adequate number and appropriate type of'fire extinguisher,
<br />barriexs toisecure •,,the area: as necessar to miniafte �trat!Eic4nd, pedestrian'/interference; florescent
<br />spray,pain 'aEEtx kank(&).'Identiftca Ion number',
<br />It shall be progect sans er''s responsibility for
<br />CORPl ianc� -yith� all �awalth a�nd,•salfe�t • pxecaut [ons��atld4,4 �uSz�m�nt� shad be_'sttictl'`y adhered to at
<br />all times during the,codrse, of •the closure -activities. „.
<br />� 1
<br />CLOSURE IN PLACE:
<br />t7f rtncurP%'in pure is suaaested_'`netliod of abandonaent: areliain_-„atv�,soil bOrinas^or �arn���� ,Tank
<br />__
<br />Closure,.aim Croce Ura
<br />ou ine en
<br />EN 23 045
<br />r i'
<br />1 u i r.° +h-
<br />I,u..iw i ., •,xLia. .$ Ft R f�
<br />'
<br />Clinics! oR
<br />Environ"ntal t1k ��
<br />Public Health Nursing
<br />Administratiotl
<br />VM ,
<br />.md' .
<br />.468-3860
<br />468-3400-3428
<br />Laboratory,•
<br />WIC
<br />Pollution
<br />Community.SWVices
<br />t, , ,
<br />x•468-3280
<br />Air
<br />468-3470
<br />4�-
<br />AIDS Information 468-3820
<br />
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