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San Joaquin County <br /> Environmental Health Department DIRECTOR <br /> 600 East Main Street Donna Heron, REHS <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> Robert McCleilon,RENS <br /> JeftCarruesco,REHS. RDI <br /> otfre "� Website: www.Sjg0v.org/ehd Kasey Foley,REHS <br /> Phone: (209)468-3420 <br /> Fax: (209)464-0138 <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: C <br /> Facility Address: !� ine.r r� c+urV_- f� �- �C` 8SC,_ 's VDC_kV a <br /> Tank(s) Number: OL <br /> Applicant's Name: Phone#: 90 Date Submitted: (0/�b 1 C <br /> [ ] 1. Applicant shall submit a written approval from the City or County Fire Prevention Bureau with jurisdiction <br /> allowing the Closure in Place (CIP) prior to the Environmental Health Department(EHD) approval. <br /> [ J 2. A registered geologist or qualifiedconsultant shall submit/sign 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$375 review fee. Any additional review time required will be assessed <br /> at $125 per hour. <br /> [ ] 4. The applicant shall submit a technical work plan 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 <br /> associated 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,a <br /> 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 SJCEHD"and remit$125 boring permit fee. <br /> a) Inspection time is charge at$125 per hour. <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 SJCEHD"form and $125 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 aerial location of the closed <br /> UST, the hazardous sub ances it on necl, and the closure method). ��} <br /> [ ] 8. REHS Approval Date: r �/ ��—L/ Y <br /> EH 23 039 (Rev 8101111) <br />