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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Crow.Pres. San Joaquin County <br /> At Cr <br /> Earl ow.Pro$rntel.Vice Pres. 1601 Fast Hazelton Avenue City of Manteca <br /> PimTommy Joyce,Secy. <br /> Stockton,California 95205 City of Escalon <br /> Jamas F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA. M.D., M.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews San <br /> of Ripon <br /> San <br /> Thomas SchuSchubert.D.V.M. Joaquin County <br /> Daphne Show City of Stockton <br /> Joaquin oa <br /> Harvey Williams.Ph.D. quin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> INSTRUCTIONS FOR COMPLETING THIS FORM <br /> FACILITY SECTION: <br /> 1. Complete form 'APPLICATION FOR PERMI "UNDRRCftOUND 7 OSURE'. <br /> A. Obtain EPA Site Number from HS (916) 324-1181 for tempo ry hazardous waste removal <br /> activities associated with mode ground tank removal <br /> B. Record name address, owner/operator,-and telephone number of the location of the <br /> underground tan(i(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 Class alongg with proof of current Yorker's <br /> Compensation insurance, or indicate if currently on file wlth this office. <br /> 3. Record the fire district and obtain the fire district permit, if applicable pprior to subaitting <br /> the "Application for Permit" to SJLHD. If the fire district requires that the �JLHD permit be issued <br /> prior to obtaining the necessary fire district permit, the fire district permit number shall be <br /> verified on site by SJLHDfield personnel during tank closure activities. Failure to provide proof <br /> of fire district permit will result in cancellation of inspection. Reinspection fees will be charged <br /> for repeat visits. <br /> 4. Record the contracted laboratory's name and telephone number. PIf 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 /> 1. DISPOSAL INFORMATION: San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> removed from site. Tank(s) will be issued an identification number which SJLHD's representative will <br /> note on the Tracking Sheet and Contractor will affix same ID Number onto tank end using florescent <br /> spray 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 to verify LEL atmosphere of tank <br /> pprior to lifting Eros excavation; adequate number and appropriate type of fire extinguisher- <br /> to to secure the area as necessary to ■inl■ize traffic and pedestrian interference; florescent <br /> spray paint to affix tank(s) identification number. It shall be project mana er's responsibility for <br /> compliance with all health and safety precautions and requirements shall be strictly adhered to at <br /> all times during the course of the closure activities. <br /> CLOSURE 10 PLACE: <br /> *jj Closu n l c u e to tto andon■ent lim n oil born ' other <br /> i;ondiPlona sols woe ; mus a coao e e nor o su ■ Ina on tea eon or ermit for Undergru_und_ Tank <br /> Closure". Obtain piocedural outline enLitieli av site work for Closuree . <br /> RH 13 045 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468.3400 468-3630 468-3420 466-3860 <br /> Air Pollution Community Servicas laboratory WIC <br /> 466-3470 465-3620 468-3460 468-3280 <br /> AIDS Information 469.3820 <br />