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7 ' BOARD OF TRUSTEES A JOAQUIN LOCAL HEALTH DIS r r CT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,sect. Stockton,California 95205 City of Escaton <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 # �' n/J(./, City of Stockton <br /> Harvey Williams,Ph.D. —1% 1 San Joaquin County <br /> CLOSURES OF UNDERGROUND STORAGE TANKS <br /> STORING HAZARDOUS MATERIALS <br /> Submit in duplicate a Work Plan describing procedures for Permanent Closur(!, <br /> Temporary Closure, or Closure in Place to San Joaquin Local Health District prior <br /> to commencing any work on subject site. The Work Plan must contain the following <br /> minimum information for review and approval: <br /> A COMPD FORM "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE": <br /> FACILITY SECTION: <br /> * Owner/Operator information <br /> CONTRACTOR SECTION: <br /> 1. Name, address, and telephone number of contractor performing removal <br /> activities. <br /> 2. Contractor's current California License and Class, along with current <br /> copies of Worker's Compensation insurance. <br /> 3. Obtain the fire district permit, if applicable, prior to submitting the <br /> "Application for Permit" to SJLHD. If the fire district requires that the <br /> SJLHD permit be issued prior to obtaining the necessary fire district permit, <br /> the fire district permit number shall be verified on site by SJLHD field <br /> personnel during tank closure activities. Failure to provide proof of fire <br /> district permit will result in cancellation of inspection. Rescheduling tank <br /> closure inspections will warrant reinspection feels) . <br /> 4. Submit contracted laboratory's name and telephone number, and contracted <br /> sampler, if different from lab and describe the method of sample collection. <br /> *Describe in detail how soil and/or water samples beneath the tank's <br /> invert will be obtained. Refer to "Sampling Protocol for Routine Tank <br /> Removals" for sampling criteria. <br /> CHEMICAL SECTION: (Do Not Write in Shaded Area) <br /> 1. List all materials stored, or previously stored, in the tank(s) . <br /> The following information shall be submitted in addition to the completed <br /> Application for Permit for Underground Tank Closure": <br /> *Obtain EPA Site Number from DOHS (916) 329-1781 for temporary hazardous waste <br /> removal activities associated with underground tank removals. <br /> *Complete the "Authorization to Release Analytical Data" form. <br /> *Procedures should explain decontamination techniques if applicable, <br /> material(s) utilized for rinsate, transportation and/or storage of hazardous <br /> waste generated on site, and specify the responsible party(ies) who will be <br /> disposing of waste generated on site. <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-3830 468-3420 468-9860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 468-3820 <br />