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pqu1N <br />cgCiFppi'`P <br />ENVIRA�MENTAL HEALTI&EPARTMENT <br />SAN JOAQUIN COUNTY <br />Donna K. Heran, R.E.H.S. <br />Director <br />Laurie A. Cotulla, R.E.H.S. <br />Assistant Director <br />600 East Main Street <br />Stockton, California 95202 <br />Telephone: (209) 468-3420 <br />Fax: (209) 468-3433 <br />CLOSURE IN PLACE <br />Business/Owner's Name: "AO U LZA '10 !W6WA\1i4c <br />Facility Address: 19111`7 1n l . I PA ST. <br />Tank(s) Number: <br />Applicant's Name: EI�F LU_ Phone No: �5-5 <br />[ ] 1. Local County/City Fire District shall approve the C <br />Department (EHD) approval. , <br />A registered geologist or qualified consultant <br />The applicant shall complete the "ApplicE <br />Hazardous Materials" form and remit a $315 <br />at $105 per hour. y <br />4. The applicant shall submit a technical <br />a) The reason for requesting a c <br />b) History of the tank site: Pre, <br />obstacle dictating boring to i <br />with the tank. <br />Program Coordinators <br />Carl Borgman, R.E.H.S. <br />Mike Huggins, R.E.H.S., R.D.I. <br />Margaret Lagorio, R.E.H.S. <br />Robert McClellon, R.E.H.S. <br />Jeff Carruesco, R.E.H.S. <br />Kasey Foley, R.E.H.S. <br />late Submitted: 7 Iy* 9 <br />in Place (CIP) prior to Environmental Health <br />the CIP proposal. <br />for Permit to Close Underground Storage Tanks Storing <br />;w fee. Any additional review time required will be assessed <br />plan which includes the details of the proposed construction: <br />and currently stored contents, tank capacity, tank location, any <br />and any failed precision tests or unauthorized releases associated <br />C) Cross-section/ous <br />n of tank and proposed angle borings. (Indicate where the borings will <br />terminate) <br />d) A minimum ongs and four soil samples per tank. (Indicate where samples will be collected) <br />e) A descriptioning protocol and types of analyses to be performed. (If water is encountered, a <br />water sampleo be collected) <br />f) Provide this othe minimum detection limits that will be utilized in the suggested analysis. <br />g) Obtain an EPcation number for hazardous waste that is generated on site. <br />h) Provide a hazaste manifest for any hazardous waste that is generated on site. <br />i) Provide methaling the boring(s) and indicate sealing material to be utilized. <br />5. The applicant shall c mplete the "Application for Permit SJCEHD" and remit $89 boring permit fee. <br />a) Inspection me is charged at $105 per hour. <br />b) The abov application shall be signed by the licensed drilling contractor or his authorized agent. (This <br />autho ' tion shall be submitted in writing.) <br />C) A sW1 ate and complete "Application for permit SJCEHD" 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 />A notice to be placed on the deed of the property (describe exact vertical and aerial location of the closed UST, <br />the hazardous substances it contained, and the closure method). <br />8. Approved by REHS: Date: <br />EH 23 039 (Rev 7/31/08) <br />