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BOARD OF TRUSTEES SAN AQUIN LOCAL HEALTH DISTRIA SERVING <br /> Al 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 Fscalon <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 HAZARD04JS 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 Humber from DHS (916) 324-1781 for temporary hazardous vaste removal <br /> activities associated with underground tank removals. <br /> 8, Record nalre address, owner/operator, and telephone number of the location of the <br /> underground taek(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, alongq 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 applicable pprior to submitting <br /> the "Application for permit" to SJLIID. If the fire district requires that the �JLHD permit be issud <br /> prior Eo obtaining the necessary fire district periait, 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 to cancellation of inspection. Reinspection fees will be charged <br /> for repeat visits. <br /> 4. Record the contracted laboratory's name and telephone number. ItIf contracted sampler is <br /> different from lab, record the name of sampling firm. l <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 Trackin Sheet will accompany each tank <br /> removed from site. Tank(s) will be issued an identification number which SJUID's representative vill <br /> note on the Tracking Sheet and Contractor will affix same ID Number onto tank end using florescent <br /> spray paint. Urldecontaminated tanks are to be tranwported under Hazardous Waste Manifest by a <br /> licensed hazardous waste hauler. <br /> 2, CONTRACTOR TO PROVIDE: Combustible/Flammable gas detector to verify LE.; atmosphere of tank <br /> prior to lifting from excavation; adequate number and a�a ropriate type of fire extinguisher' <br /> barriers to secure the area as necessary to minimize traffic and pedestrian interference, florescent <br /> sprayy 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 /> tIf Closure in Place is suested method of abandonment reliminar soil borings or other <br /> condi tone sols vor mus a C10-- e e rior Fq submt tin tca Fion orerr�t ar n erground Tank <br /> osure sin rock urs ou Inn en t e re itna_ry_ i e or or osnre tn� a __� <br /> EH 23 045 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-3400 468-38830 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-3820 468-3460 468-3280 <br /> AIDS fnlormation 468-3820 <br />