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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH DISTRICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimento(Vice Pros. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. StocktOn, California 05205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Most.M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubort.D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin 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 PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> A. Obtain EPA Site Number from DHS (916) 324-1181 for temporary hazardous waste removal <br /> activities associated with underground tank . emovals. <br /> D, Record name address, owner/operator, and telephone number of the location of the <br /> underground tan�(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, along with proof of current Worker's <br /> Compensation insurance, or indicate If currently on file with this office. <br /> 3. Record the fire district and obtain the fire district permit, if apppplicable pprior to submitting <br /> the "Application for Permit" to SJLHD. If the fire district requires that the SJLHD permit be issued <br /> prior to obtaining the necessary fire district permit, the fire district pec.uit number shall be <br /> verified on site by SJLHD field personnel durin(t 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. Mf contracted sampler is <br /> different from lab, record the name 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 /> reaoved from site, Tank(s) will be issued an identification number. winch SJLHD's representative will <br /> note on the Tracking Sheet and Contractor will affix same ID Number ontn 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 /> prior to lifting from excavation; adequate number and aropriate type of fire extinguisher- <br /> barriers to secure the area as necessary to minimize. traffic and pedestrian interference; florescent <br /> sprayy paint to affix h.ank(s) identification number. It shall be project manager's responsibility for <br /> complldrice with all health and safetyy precautions and requirements shall be strictly adhered to at <br /> all times during the course of the. closure activities. <br /> CLOSURE IN PLACE: <br /> *If CI�ss re in Place is suggested method of abandonment�_prrlliminarTsoil bgr'n s or other <br /> condltlunal soi S yor, nusFbe c:nmpTRe�rior rto"sitbaiFin "A,nnlicaf'i�n for ermi of n-en[round Tank <br /> osCl urr" — amain oznc? urd ou ine en ed�"Ir 'ieinary S�'titr.k Fbc__or;ure in�la`ce"_' <br /> EH 23 045 <br /> U � <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 460.3860 <br /> Air Pollution Community Servleea Lr.+horntory WIC <br /> 468-3470 468-3820 468-3460 468.32eO <br /> AIDS Information ann.382n <br />