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0 0 <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DMSION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />CLOSURE IN PLACE <br />Business/Owner's Name: <br />Facility Address: 1(1E <br />Tank(s) Number: 34-7P[.5_04890 weeps Number: <br />Applicant's Name: Phone No: _ <br />[✓] 1. Local County/City Fire District shall approve the <br />(PHS/EHD) approval. <br />Computer Number: _ <br />_ Date Submitted: <br />Clcsure in Place (CIP) prior to Environmental <br />[/j 2. A registered geologist or qualified consultant shall submit the CIP proposal. <br />Health Division <br />[/j 3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing Hazardous <br />Materials" form and remit a $234 review fee. Any additional review time required will be assessed at $78 per <br />hour. <br />[✓J 4. The applicant shall submit a technical workplan which includes the details of the proposed construction: <br />a) The reason for requesting a closure -in-place. <br />b) History of the tank site: Previously and currently stored contents, tank capacity, tank location, any <br />obstacle dictating boring locations, and any failed precision tests or unauthorized releasessociated with <br />the tank. <br />C) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings w I terminate) <br />d) A minimum of two borings and four soil samples per tank. (Indicate where samples will be collected) <br />e) A description of sampling protocol and types of analyses to be performed. (If water is encountered, <br />water sample shall also be collected) <br />0 Provide this office with the minimum detection limits that will be utilized in the suggested analysis. <br />g) Obtain an EPA identification number for hazardous waste that is generated on site. <br />h) Provide a hazardous waste manifest for any hazardous waste that is generated on site. <br />i) Provide method for sealing the boring(s) and indicate sealing material to be utilized. <br />(iJ 5. The applicant shall complete the "Application for Permit SJLHD" and remit $89 boring permit fee. <br />a) An initial fee of $89 includes the first hour of inspection time. If additional inspection tum is required, a <br />$78 per hour fee will be assessed. <br />b) The above application shall be signed by the licensed drilling contractor or his authorize agent. (This <br />authorization shall be submitted in writing.) <br />C) A separate and complete "Application for permit SJLHD" form and $89 permit fee is req fired for each <br />separate parcel. <br />d) The drilling contractor performing work must have on file: <br />o A copy of the C-57 well driller's license. <br />o A current copy of Worker's Compensation Insurance certificate. <br />o A completed "Contractor's Questionnaire". <br />[ j 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtai the signature <br />of the property owner or his authorized representative. <br />(] 7. A notice to be placed on the deed of the property (describe exact vertical and areal location of the cl sed UST, the <br />hazardous substances it contained, and the closure method). <br />(] 8. Approved by RENS: Date: <br />EH 23 039 (Rev 6/10/941 <br />A Division of San Joaquin County Health Care Scr.-ices <br />