Laserfiche WebLink
- <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTF,:.;T SERVING <br /> San Joaquin County <br /> At Crow,Pro& 1601 East Hazelton Avenue City of Manteca <br /> Earl Plmentel,Vice Pres. City of Escalon <br /> Tommy Joyce,Secy. Stockton, California 95205 city of Lodi <br /> James F.CulbertsonM.P.M., DISTRICT HEALTH OFFICER City of Tracy <br /> John D.Mast,M.D. JOGI KHANNA. M.D., City of Ripon <br /> Virginia Mathews San Joaquin County <br /> Thomas Schubert,D.V.M. City of Stockton <br /> Daphne Shaw San Joaquin County <br /> Harvey Williams,Ph.D. <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 fora "APPLICATION FOR PERMIT FOR UNDERGROUND TANK CLOSURE". <br /> activbties associateduvith undexgxoundltank2removalsor temporary hazardous waste removal <br /> undergcord na:e,(sldresscludeeneaiesttcr, and telephone number of the location of the <br /> CONTRACTOR SECTION: <br /> 1. Name, address, and telephone number of contractor performing removal activities. <br /> 2. Contractor's current California License and Class, alongg with proof of current Worker's <br /> Compensation insurance, or indicate 1E currently on f11e rlth this office. <br /> 3. Record the fire district and obtain the Eire district permit, ,iE apppplicable pprfoc to submitting <br /> thio"AtIlobtaion for <br /> theenecessto SfirlD.e distrif act permihe fire t,sthecfiregdistrictres apermit numbeHO r shall ermit bbeissued <br /> verified on site by SJLHD_field personnel during tank closure activities. Failure to provide proof <br /> of Eire district permit will result in cancellation of inspection. Reinspection fees will be charged <br /> for repeat visits. <br /> d4.ifferent Ethe conlabtracted laboratthe ory's <br /> of sampling telephone number. [=If contracted sampler is <br /> S. 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: 99 p <br /> each tank <br /> 1.[emovedP�so■ sHte�MATaokls)avillabeilssucdlao identalth ification numberiwhicheSJLHDls 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 Eton excavation; adequate number and appropriate type of Eire 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 far <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 /> or <br /> *If Closure in Place is sow method of abandonment c lininar soil borin s or other <br /> condi ion sof s wor nu FEe compf1e[te a oc n su mt �n a mica ors osureor rin� ace i or n e[gr°und Tank <br /> suObtain Pioutut.11,11 vutline enti.Lie r 1@lIl :a <br /> EH 23 045 <br /> Clinical Services Environmental Health Public Health Nursing <br /> Administration 468-3420 468-3860 <br /> 488-3400 468-3830 <br /> Laboratory WIC <br /> Air Pollution Community Services 468-3460 468-3280 <br /> 468-3470 468-3820 <br /> AIDS Information 468-3820 <br />