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ENV �)NMENTAL HEALTH DWISIOr <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer „ <br /> r. <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: <br /> Facility Address: o3� Ce l G �y ( A <br /> Tank(s) Number: Sweeps Number: Computer Number. <br /> Applicant's Name- ,¢{ Phone No: 7-2,3o Date Submitted: 2 <br /> ( � 1. Local County/City Fire District shall approve the Closure in Place (CIP) prior to Hnvironrnental Health <br /> Division (PHS/EHD) approval- <br /> (�}� 2. A regis r .gfolopt or qualified consultant shall submit the CIP proposal. <br /> Sex ct;4.p�. <br /> 11 3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing <br /> See_ 0* , w( Hazardous Materials' form and remit a$734 review fee. Any additional review time required will be assessed <br /> at $78 per hour. <br /> (� 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)v- 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 releases associated <br /> with the tank. <br /> c),/ Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will <br /> 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 prota:ol and types of analyses to be performed. (If water is encountered, <br /> a water sample shall also be collected) <br /> f)✓ 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)v 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 /> ( ] 5. The applicant shall complete the "Application for Permit SJLHD" and remit $89 boring permit fee. <br /> ` 1 a) An initial fee of S89 includes the first hour of inspection time. If additional inspection time is <br /> t required, a 378 per hour fee will be assessed. <br /> b) The above application shall be signed by the licensed drilling contractor or his authorized agent <br /> (This authorization shall be submitted in writing) <br /> C) A separate and complete 'Application for permit SJLHD" form and $89 permit fee is required for <br /> each separate parcel <br /> d) The drilling contractor performing work must have on Me: <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 /> (\ 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtain the <br /> signature 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 closed <br /> UST, the hazardous substances it contained, and the closure method). <br /> ( ] 8. Approved by iREHS: Date. <br /> EH 23 039 Cltev 6/10/94) A Division of San Joaquin County Health Care Services <br />