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r <br />3�- OARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br />Af Crow, Pres. San Joaquin County <br />Ead PimenteL Vice Pres. 1601 East Hazelton Avenue City of Manteca <br />Tommy Joyce, Secy. Stockton, California 95205 Ciry ofEscalon <br />James F. Culbertson City of Lodi <br />John D. Mast, M.D. JOGI 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 County <br />Daphne Shaw City of Stockton <br />Harvey Williams, PhO. San Joaquin County <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br />INSTRUCTIONS FOR COMPLETING THIS FORK <br />FACILITY SECTION: <br />1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br />A. Obtain EPA Site Number fromkDHS (916) 324-1181 for temporary hazardous waste removal <br />activities associated with underground tank removals. <br />B. Record name address, owner/opera Cor, and telephone number of the location of the <br />underground tanks). Include nearest cross street. <br />CONTRACTOR SECTION: <br />1. Name, address, and telephone number of contractor performing removal activities. <br />2. Con'tractor's current California License and Class, along pith proof of current Worker's <br />Compensation insurance, or indicate if currently on file pith this office. <br />3. Record the fire district and obtain the fire district permit, if applicable pprior to submitting <br />the "A plication 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 permit number shall be <br />verified on site by SJLHD field 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. ['If 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 />I. 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 />prior to lifting from excavation; adequate number and aopropriaLe type of fire extinguisher - <br />barriers to secure the area as necessary to minimize traltic and pedestrian interference; florescent <br />spray paint to affix tank(s) identification number. It shall be pro3en manager's responsibility for <br />compliance with all health and safety precautions and requirements shall be strictly adhered to at <br />all times during thecourseof the closure activities. <br />CLOSURE IN PLACE: <br />*If Closure in place is suggested method of abandonment reliminar sail borin s or other <br />condi lona sol 5 wor. mn5 a tomo e e or o sum t iT n , Ica ton for PEN P! or o eraround Tank <br />osure 8111 Droce ura outline entitlede.iminarv_ i.e ork Poor Quote Mace-. <br />EH 23 045 <br />Administration Clinical Services Environmental Health Public Health Nursing <br />468-3400 468-3830 468-3420 - 468-3860 <br />Air Pollution - Community Services Laboratory Wit <br />468-3470 468-3820 468-3460 468-3280 <br />