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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ernest M. Fujimoto, M.D., M.P.I., Acting Health Officer <br /> 445 N. San Joaquin Street • P.O. Box 388 • Stockton, CA 95201-0388 a <br /> (209) 468-3420 <br /> CLOS= IN PLACE <br /> f <br /> Business/Owner's Name: OL ir'Q/!4d !i%e <br /> Facility Address: Cak29 2 -7 <br /> Tank(s) Number. o Sweeps Number. Computer Number. <br /> Applicant's Namc _/Spn!". /i Phone 7-6Z9r Date Submitted: — <br /> (� 1. Local County/City Fre District shall approve the Closure in Place (CIP) prior to Environmental Health <br /> Division (PHS/EFiD) approvaL <br /> I [ / <br /> 2 A registered geologist or qualified consultant shall submit the CIP propcsaL <br /> [� 3. The applicant shall complete the "Application for Permit to Close Underground Storage 'Tanks Storing <br /> Hazardous Materials"form and remit a 5234 review fee. Any additional renew time required will be assesscd <br /> at 578 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) History of the tank site: Previously and currently stored contents, tank capacity, tank location, any <br /> obstacle dictating boring locations,and any failed precision rests or unauthorized releases associated <br /> i with the tank <br /> C) Cross-sectional drawing of tank and proposed angle borings. (Indicate when: the borings will <br /> terminate) <br /> d) A minimum of two boring and four soil samples per tank (Indicate where samples will be collected) <br /> e) A description or sampling protocol and types of analyses to be performed. (If water is encountered, <br /> a water sample shall also be collected) <br /> 1) Provide this office with the minimum detection limits thar will be utilized in the suggested analysis. <br /> g) Obtain an EPA idenrification 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 STLHD' and remit S89 boring permit fee. <br /> a) An initial fee of 589 includes the first hour of inspection time. Ir additional inspection time is <br /> required, a 578 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 STLHD* form and 589 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 /> 0 A current copy of Worker's Compensation Insurance certificate. <br /> o A completed Yvntraccoes Questionnaire <br /> [ } G The applicant shall complete the "Authorization to Release Analytical Informarion" form and obtain the <br /> signature of the property owner or his aurhorized representative. <br /> ( ) 7. A notice to be placed an the deed of the property (describe exact vertical and areal location of the closed <br /> \✓/ UST, the hazardous subs nos it contaiagd and the closure method). <br /> i <br /> B. Approved by REAS: - �r Er'i Date. J <br /> Mi 23 039 otev 6/10/94) <br /> A ni,isinn of SYn Jwquin County Health Curs•Set'+fcer <br />