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%.01 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Z' Donna K.Heran,R.E.H.S. Program Coordinators <br /> Q 600 East Main Street <br /> XDirector Carl Bergman,R.E.H.S. <br /> Stockton, California 95202 Mike Huggins,R.E.H.S.,R.D.I. <br /> Laurie A.Cotulla,R.E.H.S. Telephone: (209)468-3420 Margaret Lagorio,R.E.H.S. <br /> ��iFORa• <br /> Assistant Director Fax: (209) 468-3433 Robert McClellon,R.E.H.S. <br /> Jeff Carruesco,R.E.H.S. <br /> Kasey Foley,R.E.H.S. <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: <br /> Facility Address: <br /> Tank(s)Number: <br /> Applicant's Name: Phone No: Date Submitted: <br /> [ ] 1. Local County/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health <br /> Department(EHD)approval. <br /> [ ] 2. A registered geologist or qualified consultant 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$315 review fee. Any additional review time required will be assessed <br /> at$105 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 associated <br /> 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$89 boring permit fee. <br /> a) Inspection time is charged at$105 per hour. <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 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 /> [] 7. 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 /> [ ] <br /> S. Approved by REHS: Date: <br /> EH 23 039(Rev 7/31108) <br />