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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY 2= <br /> K: <br /> ENVIRONMENTAL HEALTH DF ISIQN <br /> Karen Furst, M.D., M.P.H., Health Officer I—lid . i, ��rY'• <br /> �/1cOR� <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 2091468-3420 <br /> CLOSURE m PLACE <br /> Business/Owner's Name: <br /> Facility Address: �� � �' Computer Number: <br /> Tank(s) Number: +�' Sweeps Number: p <br /> � e No: Date Submitted: <br /> Applicant's Name: <br /> [ j 1. Local CountylCity Fire District shafl�prove the Closure in Place (CIP) prior to Ert iiutustental !Ie lrh Division <br /> (PIIS/EHD) approval. <br /> [ ] 2. A registered geologist or qualified consultant shall submit the CIP proposal. <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 /> [ ] 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 with <br /> the tank. <br /> c) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the bovines will 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, a <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 /> [ j 5. The applicant shall complete the "Application for Permit SJLHD'. and remit SS89 boring permit fee. <br /> a) An initial fee of$89 includes the first hour of inspection time. If additional inspection time 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 authorized agent_ (This <br /> authorization shall be submitted in writing.} <br /> C) A separate and complete "Application for permit SJLHD" form and S89 permit fee is required for each <br /> separate parcel. <br /> d) The drilling contractor performing work mus: 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 obtain 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 closed UST, the <br /> hazardous substances it contained, and the closure method). <br /> [ j g_ Approved by R,EHS: <br /> Dcr1e: / 7- 9F <br /> Eli 23 477 IRe-6110M) <br /> A Division of San Joaquin Counry Health Care Scrviccs <br />