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U ! <br /> Q,,N , San Joaquin County <br /> IN l° roc Environmental Health Department DIRECTOR <br /> /Q aDonna Heran.REHS <br /> 600 East Main Street <br /> Stockton, California 95202-3029 PROGRAM COORDINATORS <br /> ' Robert McClellon,REHS <br /> \`, — •� Jeff Carruesco,REHS,RDI <br /> Website: www.sjgov.org/ehd Kasey Foley.REHS <br /> Phone: (209)468-3420 <br /> Fax: (209)464-0138 <br /> // \\ CLOSURE IN PLACE <br /> ' Business/Owner's Name: WDi( e) �_ -'� S 1� <br /> Facility Address: Nf, <br /> ' Tank(s) Number: TA 0 U 3� <br /> Applicant's Name: T_Is—►_ Phone#: 5[O `� 3 `27Dn Date Submitted: fo ]t <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 /> ' [ ] 2. A registered geologist or qualified consultant shall submittsign 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 /> 0 A copy of the C-57 welt 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�nces tained, and the closure method). <br /> ' [ ] 8. REHS Approve! Date: l© 2 f <br /> EH 23 039(Rev 8/01/11) <br />