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BOARD OF TRUSTEES So JOAQUIN LOCAL HEALTH DIACT SERVING <br /> At Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <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,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CLOSE <br /> UNDERGROUND STORAGE TANKS STORING HAZARDOUS MATERIALS <br /> INSTRUCTIONS FOR COMPLE'T'ING THIS FORM <br /> FACILITY SECTION: <br /> 1. Complete form "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> A. Obtain EPA Site Number from DOHS (916) 324-1781 for temporary hazardous waste removal <br /> activities associated with underground tank removals. <br /> B. Record name address, ovner/operator, and telephone number of the location of the <br /> underground tank(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 prior 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 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 /> 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 /> grior to lifting from excavation; adequate number and appropriate type of fire extinguisher• <br /> barriers to secure the area as necessary to minimize traffic and pedestrian interference; florescent <br /> spray paint to affix tank(s) identification number. It shall be project manager'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 IN PLACE: <br /> If Closure in Place is suHomoest method of abandonment xeliminai soil borin s or other <br /> condi lona sof s wor mus a e e nor o su mi rn ica ion of ermi or underground Tank <br /> osureObtain proceaural outline entitlea T11reilminary 41Ee wor oL osure in Place". <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 WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS Information 466-3820 <br />