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PUBLIC -HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION m ` <br /> Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> �tFOR� <br /> 445 N. San Joaquin Street • P.O. Box 388 0 Stockton, CA 95201-0388 <br /> (209) 468-3420 <br /> n/ CLOSURE IN PLACE <br /> Business/Owner's Name: (160cC.Y Ccorpofeb� <br /> Facility Address: 103L4 Ce+,n..l`cyA A--4,P _ Trio c4 t C A <br /> Tank(s) Number: Sweeps Num r. Computer Number: <br /> Applicant's Name: E_% Phone No: S/OI 1 Date Submitted: <br /> [ ] 1. Local County/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health <br /> Division (PHS/EHD) approval. <br /> [✓] 2. A registered geologist or qualified consultant shall submit the CIP proposal. <br /> [✓] 3. The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing <br /> Hazardous Materials"form and remit a$234 review fee. Any additional review time required will be assessed <br /> at $78 per hour. <br /> [ ] NA 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 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 protocol 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) 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 /> a) An initial fee of $89 includes the first hour of inspection time. If additional inspection time is <br /> required, a $78 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 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 /> [✓] 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 REHS: Date: <br /> EH 23 039 (Rev 6/10/94) A Division of San Joaquin County Hearth Care Services <br />