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PUBLIC HEALTH S ElQ ,k <br /> ICES o.P. . ....� <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelton Avenue) Stockton,California 95201 <br /> (209) 468-3400 <br /> CLOSURE IN PLACE <br /> Applicant Name: <br /> FacilityAddress: 13dJ Co <br /> _0,�7 <br /> Tank(s)Number: Sweeps Number: q <br /> 4?/F Computer Number, <br /> 1. Local County/City Fire District shall approve the CIP prior to PHS/:EHD approval. <br /> 2. A registered geologist or qualified consultant shall submit the CIP proposal. - Coyt,- sAt-eV­ <br /> 3. Complete the "Application - Environmental Health Permit/Services" form and remit a $35 workplan review fee. <br /> Additional review time required will be assessed at $35 per hour. <br /> "),go y 4�1) MX41- <br /> 7L1 <br /> 4. A technical workplan shall include a typical drawing and details of proposed construction: e,&5,e4a_ <br /> SPti -3 4, <br /> a <br /> _j,) The reason for requesting a closure-in-place. <br /> History of the tank site: Previously and currently stored contents,tank capacity,tank location,any obstacle <br /> F f/ <br /> t 5--,e dictating boring locations, and indicate if their are any failed precision tests or unauthorized releases <br /> 55ALa ssociatcd with the tank. <br /> ,' <br /> Cross-sectional drawing of tank and proposed angle boring's <br /> (Indicate where the borings will terminate) <br /> A minimum of two borings and four soil samples per tank. (Indicate where samples will be collected) <br /> _,Rr A description of sampling protocol and types of analyses to be performed. (If watel; is encount cd a <br /> neo n' <br /> C <br /> water sample shall also be collected) - 5�w_ <br /> 3 t h e s 4ue! <br /> jr;y Applicant shall provide this office with the minimum defectiotf limits that will be utilized i i the su ted <br /> analysis. <br /> Obtain an EPA identification number for hazardous wast <br /> 9-V g) e: that is generated at the site. <br /> S— Ill Provide a hazardous waste manifest for any hazardous walstc that is generated on site. <br /> Provide method for sealing the boring(s) and indicate scaling material to be utilized. <br /> 5. Complete the "Application for Permit SXHD" and remit$35 boring permit fee. <br /> 7 <br /> -A.ie_kt i me. If additional inspection time is required, <br /> 4y' An initial fee of$35 includes the first hour of inspection <br /> a $35 per hour fee will be assessed. <br /> The above application shall be signed by the licensed drilling contractor or his authorized agent. 'This <br /> authorization shall be submitted in writing. <br /> A separate and complete"Application for permit SJLHD" form and $35 permit fee is required for each <br /> differing street address. <br /> The contractor performing work must have: — elk �O jQ11L? 4,2,-77f-r�r <br /> 0 A copy of the C-57 well driller's license on file. 1: <br /> 0 A current copy of Worker's Compensation Insuriince certificate on file. <br /> 0 A completed "Contractor's Questionnaire"on file. <br /> 6- Complete the "Authorization to Release Analytical Information"form and ensure the signature of property owner <br /> or his authorized representati e. <br /> 7. Approved by REFIS. Date: <br /> EH 23 039 <br /> A Division of San Joaquin County Health Care Set Vices <br />