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%001 N104 <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> wxf <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 `1 Qac' <br /> 2091468-3420 <br /> CLOSURE IN PLACE <br /> Business/Owner's Name: 3••] ZT,- ' <br /> Facility Address: <br /> Tank(s) Number, / SoDDZ Sweeps Number: Computer Number: <br /> App icant's Name: Phone No: Date Submitted: <br /> [ 1. Local County/City Fire District shall approve the Closure in Place (CIP) prior to Environmental Health Division <br /> (PHS/EHD) approval. <br /> (vf 2. A registered geologist or qualified consultant shall submit the CIP proposal. <br /> The applicant shall complete the "Application for Permit to Close Underground Storage Tanks Storing Hazardous <br /> Materials" form and remit a $234 review fee. Any additional review time required will be assessed at S78 per <br /> hour. <br /> l✓1 4. The applicant shall submit a technical workplan 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 obstacle <br /> dictating boring locations, and any failed precision tests or unauthorized releases associated with the tank. <br /> C) Cross-sectional drawing of tank and proposed angle borings. (Indicate where the borings will 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 water <br /> sample shall also be collected) <br /> 0 Provide this office with the minimum detection limits that will be utilized in the suggested analysis. <br /> Cr) 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 /> [V,/ 5. The applicant shall complete the "Application for Permit SJLHD" and remit $89 boring permit fee. <br /> a) An initial fee of$89 includes the first hour of inspection time. If additional inspection time is required, a <br /> $78 per haur fee will be assessed. <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 SJLHD" form and $89 permit fee is required for each <br /> 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 /> [tiK 6. The applicant shall complete the "Authorization to Release Analytical Information" form and obtain the signature <br /> f of the property owner or his authorized representative. <br /> [ ]IV1�l. A notice to be placed on the deed of the property (describe exact vertical and areal location of the closed UST, the <br /> hazardous substances it contained, and the closure method). <br /> [ ] 8. Approved by RENS: Date: <br /> EH 23 0;9 (Rev 6110/94) <br /> A Division of San Joaquin County Heatth Care Services <br />